1
|
Arshad F, Ahmed S, Amjad A, Kabir M. An explainable stacking-based approach for accelerating the prediction of antidiabetic peptides. Anal Biochem 2024; 691:115546. [PMID: 38670418 DOI: 10.1016/j.ab.2024.115546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Revised: 04/20/2024] [Accepted: 04/24/2024] [Indexed: 04/28/2024]
Abstract
Diabetes is a chronic disease that is characterized by high blood sugar levels and can have several harmful outcomes. Hyperglycemia, which is defined by persistently elevated blood sugar, is one of the primary concerns. People can improve their overall well-being and get optimal health outcomes by prioritizing diabetes control. Although the use of experimental approaches in diabetes treatment is cost-effective, it necessitates the development of many strategies for evaluating the efficacy of therapies. Researchers can quickly create new strategies for managing diabetes and get vital insights by enabling virtual screening with computational tools and procedures. In this study, we suggest a predictor named STADIP (STacking-based predictor for AntiDiabetic Peptides), a new method to predict antidiabetic peptides (ADPs) utilizing a stacked-based ensemble approach. It uses 12 different feature encodings and seven machine-learning techniques to construct 84 baseline models. The impacts of various baseline models on ADP prediction were then thoroughly examined. A two-step feature selection method, eXtreme Gradient Boosting with Sequential Forward Selection (XGB-SFS), was employed to determine the optimal number, out of 84 PFs to enhance predictive performance. Subsequently, utilizing the meta-predictor approach, 45 selected PFs were integrated into an XGB classifier to formulate the final hybrid model. The proposed method demonstrated superior predictive capabilities compared to constituent baseline models, as evidenced by evaluations on both cross-validation and independent tests. During extensive independent testing, STADIP achieved promising performance with accuracy and mathew's correlation coefficient of 0.954 and 0.877, respectively. It is anticipated that it will be useful tool in helping the scientific community to identify new antidiabetic proteins.
Collapse
Affiliation(s)
- Farwa Arshad
- School of Systems and Technology, University of Management and Technology, Lahore, 54770, Pakistan.
| | - Saeed Ahmed
- School of Systems and Technology, University of Management and Technology, Lahore, 54770, Pakistan.
| | - Aqsa Amjad
- School of Systems and Technology, University of Management and Technology, Lahore, 54770, Pakistan.
| | - Muhammad Kabir
- School of Systems and Technology, University of Management and Technology, Lahore, 54770, Pakistan.
| |
Collapse
|
2
|
Ramanan M, Delaney A, Venkatesh B. Fluid therapy in diabetic ketoacidosis. Curr Opin Clin Nutr Metab Care 2024; 27:178-183. [PMID: 38126191 DOI: 10.1097/mco.0000000000001005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
PURPOSE OF REVIEW To evaluate recent evidence (2021-2023) on fluid therapy in diabetic ketoacidosis. Key evidence gaps which require generation of new evidence are discussed. RECENT FINDINGS Balanced crystalloid solutions, compared to the commonly recommended and used 0.9% sodium chloride solution (saline), may result in better outcomes for patients with diabetic ketoacidosis, including faster resolution of acidosis, less hyperchloremia and shorter hospital length of stay. Upcoming results from randomized trials may provide definitive evidence on the use of balanced crystalloid solutions in diabetic ketoacidosis. Evidence remains scarce or conflicting for the use of "two-bag" compared to conventional "one-bag" fluid, and rates of fluid administration, especially for adult patients. In children, concerns about cerebral oedema from faster fluid administration rates have not been demonstrated in cohort studies nor randomized trials. SUMMARY Fluid therapy is a key aspect of diabetic ketoacidosis management, with important evidence gaps persisting for several aspects of management despite recent evidence.
Collapse
Affiliation(s)
- Mahesh Ramanan
- Caboolture and The Prince Charles Hospitals, Metro North Hospital and Health Services, Brisbane, Queensland
- Critical Care Division, The George Institute for Global Health, Sydney, New South Wales
- James Mayne Academy of Critical Care, The University of Queensland, St Lucia, Queensland
| | - Anthony Delaney
- Critical Care Division, The George Institute for Global Health, Sydney, New South Wales
- Royal North Shore Hospital, St Leonards, New South Wales
| | - Balasubramanian Venkatesh
- Critical Care Division, The George Institute for Global Health, Sydney, New South Wales
- Wesley Hospital, Auchenflower, Queensland, Australia
| |
Collapse
|
3
|
Uhlig M, Karasimos E. Quiz intensiv – stellen Sie die Diagnose! Anasthesiol Intensivmed Notfallmed Schmerzther 2023; 58:195-198. [PMID: 36958315 DOI: 10.1055/a-1888-6512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/25/2023]
|
4
|
Dhatariya KK. The management of diabetic ketoacidosis in adults-An updated guideline from the Joint British Diabetes Society for Inpatient Care. Diabet Med 2022; 39:e14788. [PMID: 35224769 DOI: 10.1111/dme.14788] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 01/11/2022] [Indexed: 12/20/2022]
Abstract
This article summarises the Joint British Diabetes Societies for Inpatient Care guidelines on the management of ketoacidosis; available at https://abcd.care/resource/management-diabetic-ketoacidosis-dka-adults. The document explicitly states that when a person aged 16-18 is under the care of the paediatric team, then the paediatric guideline should be used, and if they are cared for by an adult team, then this guideline should be used. The guideline takes into account new evidence on the use of the previous version of this document, particularly the high prevalence of hypoglycaemia and hypokalaemia, and recommends that when the glucose concentration drops below 14 mmol/L, that de-escalating the insulin infusion rate from 0.1 to 0.05 units/kg/h should be considered. Furthermore, a section has been added to address the recognition that use of sodium glucose co-transporter 2 inhibitors is associated with an increased risk of euglycaemic ketoacidosis. The management of ketoacidosis in people with end-stage renal failure or on dialysis is also mentioned. Finally, the algorithms to illustrate the guideline have been updated.
Collapse
Affiliation(s)
- Ketan K Dhatariya
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
- Norwich Medicine School, University of East Anglia, Norwich, UK
| |
Collapse
|
5
|
Rao P, Jiang SF, Kipnis P, Patel DM, Katsnelson S, Madani S, Liu VX. Evaluation of Outcomes Following Hospital-Wide Implementation of a Subcutaneous Insulin Protocol for Diabetic Ketoacidosis. JAMA Netw Open 2022; 5:e226417. [PMID: 35389497 PMCID: PMC8990349 DOI: 10.1001/jamanetworkopen.2022.6417] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Standard diabetic ketoacidosis care in the US includes intravenous insulin treatment in the intensive care unit. Subcutaneous (SQ) insulin could decrease intensive care unit need, but the data are limited. OBJECTIVE To assess outcomes after implementation of an SQ insulin protocol for treating diabetic ketoacidosis. DESIGN, SETTING, AND PARTICIPANTS This cohort study is a retrospective evaluation of a prospectively implemented SQ insulin protocol. The study was conducted at an integrated health care system in Northern California. Participants included hospitalized patients with diabetic ketoacidosis at 21 hospitals between January 1, 2010, and December 31, 2019. The preimplementation phase was 2010 to 2015, and the postimplementation phase was 2017 to 2019. Data analysis was performed from October 2020 to January 2022. EXPOSURE An SQ insulin treatment protocol for diabetic ketoacidosis. MAIN OUTCOMES AND MEASURES Difference-in-differences evaluation of the need for intensive care, mortality, readmission, and length of stay at a single intervention site using an SQ insulin protocol from 2017 onward compared with 20 control hospitals using standard care. RESULTS A total of 7989 hospitalizations for diabetic ketoacidosis occurred, with 4739 (59.3%) occurring before and 3250 (40.7%) occurring after implementation. The overall mean (SD) age was 42.3 (17.7) years, with 4137 hospitalizations (51.8%) occurring among female patients. Before implementation, SQ insulin was the first insulin used in 40 intervention (13.4%) and 651 control (14.7%) hospitalizations. After implementation, 98 hospitalizations (80.3%) received SQ insulin first at the intervention site compared with 402 hospitalizations (12.8%) at control sites. The adjusted rate ratio for intensive care unit admission was 0.43 (95% CI, 0.33-0.56) at the intervention sites, a 57% reduction compared with control sites, and was 0.50 (95% CI, 0.25-0.99) for 30-day hospital readmission, a 50% reduction. There were no significant changes in hospital length of stay and rates of death. CONCLUSIONS AND RELEVANCE These findings suggest that a protocol based on SQ insulin for diabetic ketoacidosis treatment was associated with significant decreases in intensive care unit need and readmission, with no evidence of increases in adverse events.
Collapse
Affiliation(s)
- Priya Rao
- Kaiser Permanente San Jose Medical Center, San Jose, California
- The Permanente Medical Group, Oakland, California
| | | | - Patricia Kipnis
- The Permanente Medical Group, Oakland, California
- Kaiser Permanente Division of Research, Oakland, California
| | - Divyesh M. Patel
- Kaiser Permanente San Jose Medical Center, San Jose, California
- The Permanente Medical Group, Oakland, California
| | - Svetlana Katsnelson
- Kaiser Permanente San Jose Medical Center, San Jose, California
- The Permanente Medical Group, Oakland, California
| | - Samineh Madani
- Kaiser Permanente San Jose Medical Center, San Jose, California
- The Permanente Medical Group, Oakland, California
| | - Vincent X. Liu
- The Permanente Medical Group, Oakland, California
- Kaiser Permanente Division of Research, Oakland, California
| |
Collapse
|
6
|
Eledrisi MS, Elzouki AN. Management of Diabetic Ketoacidosis in Adults: A Narrative Review. SAUDI JOURNAL OF MEDICINE & MEDICAL SCIENCES 2020; 8:165-173. [PMID: 32952507 PMCID: PMC7485658 DOI: 10.4103/sjmms.sjmms_478_19] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 02/20/2020] [Accepted: 06/02/2020] [Indexed: 12/20/2022]
Abstract
Diabetic ketoacidosis (DKA) is the most common hyperglycemic emergency and causes the greatest risk for death in patients with diabetes mellitus. DKA more commonly occurs among those with type 1 diabetes, yet almost a third of the cases occur among those with type 2 diabetes. Although mortality rates from DKA have declined to low levels in general, it continues to be high in many developing countries. DKA is characterized by hyperglycemia, metabolic acidosis and ketosis. Proper management of DKA requires hospitalization for aggressive intravenous fluids, insulin therapy, electrolyte replacement as well as identification and treatment of the underlying precipitating event along with frequent monitoring of patient's clinical and laboratory states. The most common precipitating causes for DKA include infections, new diagnosis of diabetes and nonadherence to insulin therapy. Clinicians should be aware of the occurrence of DKA in patients prescribed sodium-glucose co-transporter 2 inhibitors. Discharge plans should include appropriate choice and dosing of insulin regimens and interventions to prevent recurrence of DKA. Future episodes of DKA can be reduced through patient education programs focusing on adherence to insulin and self-care guidelines during illness and improved access to medical providers. New approaches such as extended availability of phone services, use of telemedicine and utilization of public campaigns can provide further support for the prevention of DKA.
Collapse
Affiliation(s)
- Mohsen S Eledrisi
- Department of Medicine, Hamad Medical Corporation, Doha, Qatar.,Department of Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Abdel-Naser Elzouki
- Department of Medicine, Hamad Medical Corporation, Doha, Qatar.,Department of Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar
| |
Collapse
|
7
|
Abstract
Diabetic ketoacidosis (DKA) is the most common acute hyperglycaemic emergency in people with diabetes mellitus. A diagnosis of DKA is confirmed when all of the three criteria are present - 'D', either elevated blood glucose levels or a family history of diabetes mellitus; 'K', the presence of high urinary or blood ketoacids; and 'A', a high anion gap metabolic acidosis. Early diagnosis and management are paramount to improve patient outcomes. The mainstays of treatment include restoration of circulating volume, insulin therapy, electrolyte replacement and treatment of any underlying precipitating event. Without optimal treatment, DKA remains a condition with appreciable, although largely preventable, morbidity and mortality. In this Primer, we discuss the epidemiology, pathogenesis, risk factors and diagnosis of DKA and provide practical recommendations for the management of DKA in adults and children.
Collapse
Affiliation(s)
- Ketan K Dhatariya
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Colney Lane, Norwich, Norfolk, UK.,Norwich Medical School, University of East Anglia, Norfolk, UK
| | - Nicole S Glaser
- Department of Pediatrics, University of California Davis, School of Medicine, Sacramento, CA, USA
| | - Ethel Codner
- Institute of Maternal and Child Research, School of Medicine, University of Chile, Santiago, Chile
| | | |
Collapse
|
8
|
Merrill JD, Soliman D, Kumar N, Lim S, Shariff AI, Yancy WS. Low-Carbohydrate and Very-Low-Carbohydrate Diets in Patients With Diabetes. Diabetes Spectr 2020; 33:133-142. [PMID: 32425450 PMCID: PMC7228825 DOI: 10.2337/ds19-0070] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Low-carbohydrate diets have been advocated as an effective method for promoting weight loss in overweight and obese individuals and preventing and treating type 2 diabetes. This article reviews the differences between various low-carbohydrate eating plans and discusses the benefits and drawbacks of such a diet based on available evidence. It also offers practical pointers for clinicians.
Collapse
Affiliation(s)
- Jennifer D. Merrill
- Division of Endocrinology, Diabetes and Metabolism, Duke University School of Medicine, Durham, NC
| | - Diana Soliman
- Division of Endocrinology, Diabetes and Metabolism, Duke University School of Medicine, Durham, NC
| | - Nitya Kumar
- Division of Endocrinology, Diabetes and Metabolism, Duke University School of Medicine, Durham, NC
| | - Sooyoung Lim
- Department of Internal Medicine, Duke University School of Medicine, Durham, NC
| | - Afreen I. Shariff
- Division of Endocrinology, Diabetes and Metabolism, Duke University School of Medicine, Durham, NC
| | - William S. Yancy
- Duke Diet and Fitness Center, Department of Medicine, Duke University Health System, Durham, NC
- Durham Veterans Affairs Medical Center, Durham, NC
| |
Collapse
|
9
|
Jung B, Martinez M, Claessens YE, Darmon M, Klouche K, Lautrette A, Levraut J, Maury E, Oberlin M, Terzi N, Viglino D, Yordanov Y, Claret PG, Bigé N. Diagnostic et Prise en Charge de l’Acidose Métabolique Recommandations formalisées d’experts communes Société de réanimation de langue française (SRLF) – Société française de médecine d’urgence (SFMU). ANNALES FRANCAISES DE MEDECINE D URGENCE 2019. [DOI: 10.3166/afmu-2019-0162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
L’acidose métabolique est un trouble fréquemment rencontré en médecine d’urgence et en médecine intensive réanimation. La littérature s’étant enrichie de nouvelles données concernant la prise en charge de l’acidose métabolique, la Société de Réanimation de Langue Française (SRLF) et la Société Française de Médecine d’Urgence (SFMU) ont élaboré des recommandations formalisées d’experts selon la méthodologie GRADE. Les champs de la stratégie diagnostique, de l’orientation et de la prise en charge thérapeutique ont été traités et vingt-neuf recommandations ont été formulées : quatre recommandations fortes (Grade 1), dix recommandations faibles (Grade 2) et quinze avis d’experts. Toutes ont obtenu un accord fort. L’application des méthodes d’Henderson-Hasselbalch et de Stewart pour le diagnostic du mécanisme de l’acidose métabolique est discutée et un algorithme diagnostique est proposé. L’utilisation de la cétonémie et des lactatémies veineuse et capillaire est également traitée. L’intérêt du pH, de la lactatémie et de sa cinétique pour l’orientation des patients en pré-hospitalier et aux urgences est envisagé. Enfin, les modalités de l’insulinothérapie au cours de l’acidocétose diabétique, les indications de la perfusion de bicarbonate de sodium et de l’épuration extra-rénale ainsi que les modalités de la ventilation mécanique au cours des acidoses métaboliques sévères sont traitées dans la prise en charge thérapeutique.
Collapse
|
10
|
Jung B, Martinez M, Claessens YE, Darmon M, Klouche K, Lautrette A, Levraut J, Maury E, Oberlin M, Terzi N, Viglino D, Yordanov Y, Claret PG, Bigé N. Diagnosis and management of metabolic acidosis: guidelines from a French expert panel. Ann Intensive Care 2019; 9:92. [PMID: 31418093 PMCID: PMC6695455 DOI: 10.1186/s13613-019-0563-2] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 07/30/2019] [Indexed: 02/07/2023] Open
Abstract
Metabolic acidosis is a disorder frequently encountered in emergency medicine and intensive care medicine. As literature has been enriched with new data concerning the management of metabolic acidosis, the French Intensive Care Society (Société de Réanimation de Langue Française [SRLF]) and the French Emergency Medicine Society (Société Française de Médecine d’Urgence [SFMU]) have developed formalized recommendations from experts using the GRADE methodology. The fields of diagnostic strategy, patient assessment, and referral and therapeutic management were addressed and 29 recommendations were made: 4 recommendations were strong (Grade 1), 10 were weak (Grade 2), and 15 were experts’ opinions. A strong agreement from voting participants was obtained for all recommendations. The application of Henderson–Hasselbalch and Stewart methods for the diagnosis of the metabolic acidosis mechanism is discussed and a diagnostic algorithm is proposed. The use of ketosis and venous and capillary lactatemia is also treated. The value of pH, lactatemia, and its kinetics for the referral of patients in pre-hospital and emergency departments is considered. Finally, the modalities of insulin therapy during diabetic ketoacidosis, the indications for sodium bicarbonate infusion and extra-renal purification as well as the modalities of mechanical ventilation during severe metabolic acidosis are addressed in therapeutic management.
Collapse
Affiliation(s)
- Boris Jung
- Département de Médecine Intensive et Réanimation, CHU Montpellier, 34000, Montpellier, France. .,INSERM U-1046, CNRS U-9234 (PhyMedExp), Université de Montpellier, Montpellier, France.
| | - Mikaël Martinez
- Pôle Urgence, CH du Forez, 42605, Montbrison, France.,Réseau d'urgence Ligérien Ardèche Nord (REULIAN), Centre Hospitalier Le Corbusier, 42700, Firminy, France
| | - Yann-Erick Claessens
- Département de Médecine d'urgence, Centre Hospitalier Princesse-Grace, Avenue Pasteur, 98012, Monaco, France
| | - Michaël Darmon
- Unité de Médecine Intensive et Réanimation, Hôpital Universitaire Saint-Louis, Assistance Publique-Hôpitaux de Paris, Avenue Claude-Vellefaux, 75010, Paris, France.,Faculté de Médecine, Université Paris-Diderot, Sorbonne-Paris-Cité, Paris, France.,France Inserm, ECSTRA Team, UMR 1153, Centre d'Epidémiologie et de Biostatistique, CRESS, Biostatistics and Clinical Epidemiology, Sorbonne-Paris-Cité, Paris, France
| | - Kada Klouche
- INSERM U-1046, CNRS U-9234 (PhyMedExp), Université de Montpellier, Montpellier, France.,Département de Médecine Intensive-Réanimation, CHU Lapeyronie, 371, Avenue Doyen-Gaston-Giraud, 34295, Montpellier, France
| | - Alexandre Lautrette
- Réanimation, Centre Jean-Perrin, CHU de Clermont-Ferrand, 63000, Clermont-Ferrand, France.,LMGE, UMR CNRS 6023, Université Clermont-Auvergne, Clermont-Ferrand, France
| | - Jacques Levraut
- Département de Médecine d'urgence, CHU de Nice, Hôpital Pasteur-II, 30, Avenue de la Voie Romaine, 06000, Nice, France.,UFR de Médecine, Université de Nice Côte d'Azur, Avenue de Vallombrose, 06000, Nice, France
| | - Eric Maury
- Service de Médecine Intensive-Réanimation, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, 184, Rue du Faubourg-Saint-Antoine, 75571 Paris Cedex 12, Paris, France.,Sorbonne Université, Université Pierre-et-Marie Curie-Paris-VI, Paris, France.,Inserm U1136, 75012, Paris, France
| | - Mathieu Oberlin
- Structure des Urgences, Centre Hospitalier de Cahors, 335, Rue Wilson, 46000, Cahors, France
| | - Nicolas Terzi
- Service de Médecine Intensive-Réanimation, Centre Hospitalier Universitaire de Grenoble, Université de Grenoble, Grenoble, France.,Inserm, U1042, Université Grenoble-Alpes, HP2, 38000, Grenoble, France
| | - Damien Viglino
- Service des Urgences Adultes, CS 10217, CHU Grenoble-Alpes, 38043 Grenoble Cedex 09, Grenoble, France.,Inserm U1042, Laboratoire HP2 Hypoxie-Physiopathologies, Université Grenoble-Alpes, Grenoble, France
| | - Youri Yordanov
- Faculté de Médecine, Sorbonne Universités, 75013, Paris, France.,Inserm, U1153, Université Paris-Descartes, 75006, Paris, France.,Service des Urgences, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), 75012, Paris, France
| | - Pierre-Géraud Claret
- Pôle Anesthésie Réanimation Douleur Urgences, Centre Hospitalier Universitaire de Nîmes, 4, Rue du Professeur-Robert-Debré, 30029, Nîmes, France
| | - Naïke Bigé
- Service de Médecine Intensive-Réanimation, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, 184, Rue du Faubourg-Saint-Antoine, 75571 Paris Cedex 12, Paris, France
| | | | | |
Collapse
|
11
|
|
12
|
Affiliation(s)
- TERRY J. HANNAN
- Sutherland HospitalSydney
- The Sutherland HospitalP.O. Box 21CaringbahN.S.W.2229
| | | |
Collapse
|
13
|
Usman A, Makmor Bakry M, Mustafa N, Rehman IU, Bukhsh A, Lee SWH, Khan TM. Correlation of acidosis-adjusted potassium level and cardiovascular outcomes in diabetic ketoacidosis: a systematic review. Diabetes Metab Syndr Obes 2019; 12:1323-1338. [PMID: 31496770 PMCID: PMC6689561 DOI: 10.2147/dmso.s208492] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 06/05/2019] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND During the progress and resolution of a diabetic ketoacidosis (DKA) episode, potassium levels are significantly affected by the extent of acidosis. However, none of the current guidelines take into account acidosis during resuscitation of potassium level in DKA management, which may increase the risk of cardiovascular adverse events. OBJECTIVE To assess literature regarding the adjustment of potassium level using pH to calculate pH-adjusted corrected potassium level, and to observe the relationship of cardiovascular outcomes with reported potassium level and pH-adjusted corrected potassium in DKA. METHODOLOGY Seven databases were searched from inception to January 2018 for studies which had reported people with diabetes developing diabetic ketoacidosis, in relation to prevalence or incidence, fluid resuscitation or potassium supplementation treatment, treatment or cardiovascular outcomes, and experimentation with DKA management or insulin. Quality of studies was evaluated using Cochrane Risk of Bias and Newcastle Ottawa Scale. RESULTS Forty-seven studies were included in qualitative synthesis out of a total of 10,292 retrieved studies. Forty-one studies discussed the potassium level and blood pH at the time of admission, ten studies discussed cardiovascular outcomes, and only four studies concurrently discussed potassium level, pH, and cardiovascular outcomes. Only two studies were graded as good on the Newcastle Ottawa Scale. The reported potassium level was well within normal range (5.8 mmol/L), whereas pH rendered patients to be moderately acidotic (7.13). Surprisingly, none of the included studies mentioned pH-adjusted corrected potassium level and, hence, this was calculated later. Although mean corrected potassium was within the normal range (3.56 mmol/L), 13 studies had corrected potassium below 3.5 mmol/L and five had it below 3.0 mmol/L. Nevertheless, with the exception of one study, none discussed cardiovascular outcomes in the context of potassium or pH-adjusted potassium level. CONCLUSION The evidence surrounding cardiovascular outcomes during DKA episodes in light of a pH-adjusted corrected potassium level is scarce. A prospective observational, or preferably, an experimental study in this regard will ensure we can modify and enhance safety of existing DKA treatment protocols.
Collapse
Affiliation(s)
- Atif Usman
- School of Pharmacy, Monash University, Bandar Sunway, Selangor, Malaysia
- Correspondence: Atif UsmanSchool of Pharmacy, Monash University Malaysia, Jalan Lagoon Selatan47500, Bandar Sunway, Selangor, MalaysiaEmail
| | - Mohd Makmor Bakry
- Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Norlaila Mustafa
- Department of Endocrinology, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Inayat Ur Rehman
- School of Pharmacy, Monash University, Bandar Sunway, Selangor, Malaysia
- Department of Pharmacy, Abdul Wali Khan University, Mardan, Pakistan
| | - Allah Bukhsh
- School of Pharmacy, Monash University, Bandar Sunway, Selangor, Malaysia
- Institute of Pharmaceutical Sciences, University of Veterinary and Animal Sciences, Lahore, Pakistan
| | - Shaun Wen Huey Lee
- School of Pharmacy, Monash University, Bandar Sunway, Selangor, Malaysia
| | - Tahir Mehmood Khan
- School of Pharmacy, Monash University, Bandar Sunway, Selangor, Malaysia
- Institute of Pharmaceutical Sciences, University of Veterinary and Animal Sciences, Lahore, Pakistan
- Asian Centre for Evidence Synthesis in Population, Implementation and Clinical Outcomes, Health and Well-being Cluster, Global Asia in the 21st Century Platform, Monash University Malaysia, Selangor, Malaysia
- Tahir Mehmood KhanSchool of Pharmacy, Monash University Malaysia, Jalan Lagoon Selatan47500, Bandar Sunway, Selangor, MalaysiaEmail ;
| |
Collapse
|
14
|
|
15
|
Affiliation(s)
- D A Pyke
- Diabetic Department, King's College Hospital, London SE5
| |
Collapse
|
16
|
Dhatariya KK, Vellanki P. Treatment of Diabetic Ketoacidosis (DKA)/Hyperglycemic Hyperosmolar State (HHS): Novel Advances in the Management of Hyperglycemic Crises (UK Versus USA). Curr Diab Rep 2017; 17:33. [PMID: 28364357 PMCID: PMC5375966 DOI: 10.1007/s11892-017-0857-4] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are diabetic emergencies that cause high morbidity and mortality. Their treatment differs in the UK and USA. This review delineates the differences in diagnosis and treatment between the two countries. RECENT FINDINGS Large-scale studies to determine optimal management of DKA and HHS are lacking. The diagnosis of DKA is based on disease severity in the USA, which differs from the UK. The diagnosis of HHS in the USA is based on total rather than effective osmolality. Unlike the USA, the UK has separate guidelines for DKA and HHS. Treatment of DKA and HHS also differs with respect to timing of fluid and insulin initiation. There is considerable overlap but important differences between the UK and USA guidelines for the management of DKA and HHS. Further research needs to be done to delineate a unifying diagnostic and treatment protocol.
Collapse
Affiliation(s)
- Ketan K Dhatariya
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Colney Lane, Norwich, Norfolk, NR4 7UY, UK.
- University of East Anglia, Norwich Research Park, Norwich, NR4 7TJ, UK.
| | - Priyathama Vellanki
- Division of Endo, Metabolism & Lipids, Emory University School of Medicine, Atlanta, GA, USA
| |
Collapse
|
17
|
Klein-Schwartz W, Stassinos GL, Isbister GK. Treatment of sulfonylurea and insulin overdose. Br J Clin Pharmacol 2016; 81:496-504. [PMID: 26551662 DOI: 10.1111/bcp.12822] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 11/02/2015] [Accepted: 11/03/2015] [Indexed: 11/26/2022] Open
Abstract
The most common toxicity associated with sulfonylureas and insulin is hypoglycaemia. The article reviews existing evidence to better guide hypoglycaemia management. Sulfonylureas and insulin have narrow therapeutic indices. Small doses can cause hypoglycaemia, which may be delayed and persistent. All children and adults with intentional overdoses need to be referred for medical assessment and treatment. Unintentional supratherapeutic ingestions can be initially managed at home but if symptomatic or if there is persistent hypoglycaemia require medical referral. Patients often require intensive care and prolonged observation periods. Blood glucose concentrations should be assessed frequently. Asymptomatic children with unintentional sulfonylurea ingestions should be observed for 12 h, except if this would lead to discharge at night when they should be kept until the morning. Prophylactic intravenous dextrose is not recommended. The goal of therapy is to restore and maintain euglycaemia for the duration of the drug's toxic effect. Enteral feeding is recommended in patients who are alert and able to tolerate oral intake. Once insulin or sulfonylurea-induced hypoglycaemia has developed, it should be initially treated with an intravenous dextrose bolus. Following this the mainstay of therapy for insulin-induced hypoglycaemia is intravenous dextrose infusion to maintain the blood glucose concentration between 5.5 and 11 mmol l(-1) . After sulfonylurea-induced hypoglycaemia is initially corrected with intravenous dextrose, the main treatment is octreotide which is administered to prevent insulin secretion and maintain euglycaemia. The observation period varies depending on drug, product formulation and dose. A general guideline is to observe for 12 h after discontinuation of intravenous dextrose and, if applicable, octreotide.
Collapse
Affiliation(s)
- Wendy Klein-Schwartz
- Maryland Poison Center, Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, USA
| | - Gina L Stassinos
- Maryland Poison Center, Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, USA
| | - Geoffrey K Isbister
- Clinical Toxicology Research Group, University of Newcastle, Newcastle, Australia
| |
Collapse
|
18
|
Wang SP, Yang H, Wu JW, Gauthier N, Fukao T, Mitchell GA. Metabolism as a tool for understanding human brain evolution: lipid energy metabolism as an example. J Hum Evol 2014; 77:41-9. [PMID: 25488255 DOI: 10.1016/j.jhevol.2014.06.013] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2013] [Revised: 03/24/2014] [Accepted: 06/18/2014] [Indexed: 10/24/2022]
Abstract
Genes and the environment both influence the metabolic processes that determine fitness. To illustrate the importance of metabolism for human brain evolution and health, we use the example of lipid energy metabolism, i.e. the use of fat (lipid) to produce energy and the advantages that this metabolic pathway provides for the brain during environmental energy shortage. We briefly describe some features of metabolism in ancestral organisms, which provided a molecular toolkit for later development. In modern humans, lipid energy metabolism is a regulated multi-organ pathway that links triglycerides in fat tissue to the mitochondria of many tissues including the brain. Three important control points are each suppressed by insulin. (1) Lipid reserves in adipose tissue are released by lipolysis during fasting and stress, producing fatty acids (FAs) which circulate in the blood and are taken up by cells. (2) FA oxidation. Mitochondrial entry is controlled by carnitine palmitoyl transferase 1 (CPT1). Inside the mitochondria, FAs undergo beta oxidation and energy production in the Krebs cycle and respiratory chain. (3) In liver mitochondria, the 3-hydroxy-3-methylglutaryl-CoA (HMG-CoA) pathway produces ketone bodies for the brain and other organs. Unlike most tissues, the brain does not capture and metabolize circulating FAs for energy production. However, the brain can use ketone bodies for energy. We discuss two examples of genetic metabolic traits that may be advantageous under most conditions but deleterious in others. (1) A CPT1A variant prevalent in Inuit people may allow increased FA oxidation under nonfasting conditions but also predispose to hypoglycemic episodes. (2) The thrifty genotype theory, which holds that energy expenditure is efficient so as to maximize energy stores, predicts that these adaptations may enhance survival in periods of famine but predispose to obesity in modern dietary environments.
Collapse
Affiliation(s)
- Shu Pei Wang
- Division of Medical Genetics, Department of Pediatrics, Université de Montréal and CHU Sainte-Justine, 3175 Côte Sainte-Catherine, Montreal H3T 1C5, QC, Canada
| | - Hao Yang
- Division of Medical Genetics, Department of Pediatrics, Université de Montréal and CHU Sainte-Justine, 3175 Côte Sainte-Catherine, Montreal H3T 1C5, QC, Canada; Laboratory of Animal Fat Deposition and Muscle Development, College of Animal Science and Technology, Northwest A&F University, Yangling 712100, Shaanxi, China
| | - Jiang Wei Wu
- Division of Medical Genetics, Department of Pediatrics, Université de Montréal and CHU Sainte-Justine, 3175 Côte Sainte-Catherine, Montreal H3T 1C5, QC, Canada
| | - Nicolas Gauthier
- Division of Medical Genetics, Department of Pediatrics, Université de Montréal and CHU Sainte-Justine, 3175 Côte Sainte-Catherine, Montreal H3T 1C5, QC, Canada
| | - Toshiyuki Fukao
- Department of Pediatrics, Gifu University School of Medicine, Gifu 500, Japan
| | - Grant A Mitchell
- Division of Medical Genetics, Department of Pediatrics, Université de Montréal and CHU Sainte-Justine, 3175 Côte Sainte-Catherine, Montreal H3T 1C5, QC, Canada.
| |
Collapse
|
19
|
Reddy P, Duggar B, Butterworth J. Blood glucose management in the patient undergoing cardiac surgery: A review. World J Cardiol 2014; 6:1209-17. [PMID: 25429332 PMCID: PMC4244617 DOI: 10.4330/wjc.v6.i11.1209] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2013] [Revised: 08/27/2014] [Accepted: 09/16/2014] [Indexed: 02/07/2023] Open
Abstract
Both diabetes mellitus and hyperglycemia per se are associated with negative outcomes after cardiac surgery. In this article, we review these associations, the possible mechanisms that lead to adverse outcomes, and the epidemiology of diabetes focusing on those patients requiring cardiac surgery. We also examine outpatient and perioperative management of diabetes with the same focus. Finally, we discuss our own efforts to improve glycemic management of patients undergoing cardiac surgery at our institution, including keys to success, results of implementation, and patient safety concerns.
Collapse
Affiliation(s)
- Pingle Reddy
- Pingle Reddy, Brian Duggar, John Butterworth, Department of Anesthesiology, Virginia Commonwealth University, Richmond, VA 232298-0695, United States
| | - Brian Duggar
- Pingle Reddy, Brian Duggar, John Butterworth, Department of Anesthesiology, Virginia Commonwealth University, Richmond, VA 232298-0695, United States
| | - John Butterworth
- Pingle Reddy, Brian Duggar, John Butterworth, Department of Anesthesiology, Virginia Commonwealth University, Richmond, VA 232298-0695, United States
| |
Collapse
|
20
|
Affiliation(s)
- Stuart J Brink
- New England Diabetes and Endocrinology Center (NEDEC), Waltham, MA, USA, and Associate Clinical Professor of Pediatrics; Tufts University School of Medicine; Boston MA USA
| |
Collapse
|
21
|
Jivan D. Management of diabetic ketoacidosis. JOURNAL OF ENDOCRINOLOGY METABOLISM AND DIABETES OF SOUTH AFRICA 2014. [DOI: 10.1080/22201009.2011.10872247] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- D Jivan
- Department of Medicine, Division of Endocrinology and Metabolism, University of the Witwatersrand
| |
Collapse
|
22
|
He S, Wang D, Wei L. Practical and critical instruction for nonhuman primate diabetic models. Transplant Proc 2014; 45:1856-65. [PMID: 23769058 DOI: 10.1016/j.transproceed.2012.11.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2012] [Accepted: 11/20/2012] [Indexed: 02/05/2023]
Abstract
Diabetes mellitus, a disease of metabolic dysregulation, is characterized by inappropriate hyperglycemia resulting from progressive loss of insulin secretion or action. The potential of nonhuman primate (NHP) models in diabetes research has been well understood. NHPs have long been regarded as the "gold standard" for preclinical studies. However, there are persistent, severe obstacles to the development and application of these models. At present, a consensus for standardized strategies of diabetic induction has not been achieved. The different modeling methods of diabetes has led to various characterizations of the pathology of the disease; however, there are deficiencies of systemic evaluation programs for nonhuman primate diabetes models. In this scenario, experimental systemic programs provide the highly required guidelines for NHP diabetic models. Moreover, given the expensive and relatively small population of primates and the fatal diabetic complications, it is imperative to carefully manage the care and use of these animals in biomedical research studies. This article briefly reviews the technical and managerial aspects of NHP diabetes models providing practical and critical instruction on housing and care, routine management, development strategy, modeling diagnosis, evaluation, and disease control, as well as guidelines for model selection for various purposes. The present article sought to provide guidelines for NHP models of diabetes in their development and application. It is not intended to outline mandatory requirements for clinical accreditation.
Collapse
Affiliation(s)
- S He
- Laboratory of Transplant Engineering and Immunology, Regenerative Medicine Research Center, West China Hospital, Sichuan University, and the Center for Cell Transplantation (Seventh Unit of General Surgery Department), Institute of Organ Transplantation, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, PR China
| | | | | |
Collapse
|
23
|
Devi R, Selvakumar G, Clark L, Downer C, Braithwaite SS. A dose-defining insulin algorithm for attainment and maintenance of glycemic targets during therapy of hyperglycemic crises. ACTA ACUST UNITED AC 2011. [DOI: 10.2217/dmt.11.18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
|
24
|
Jolobe OMP. Potassium status should be evaluated also when diabetic ketoacidosis is complicated by heart failure. Am J Emerg Med 2011; 29:955-6. [PMID: 21665417 DOI: 10.1016/j.ajem.2011.05.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2011] [Accepted: 05/07/2011] [Indexed: 01/19/2023] Open
|
25
|
|
26
|
Eskildsen PC, Nerup J. Low-dose insulin treatment of diabetic ketoacidosis. ACTA MEDICA SCANDINAVICA 2009; 202:295-300. [PMID: 411330 DOI: 10.1111/j.0954-6820.1977.tb16830.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Twenty-four consecutively admitted episodes of acute diabetic dysregulation in 22 patients were treated with a low-dose insulin regimen, given as hourly i.m. injections of 5 IU insulin. The fall in blood glucose was almost linear during the first 8 hours of treatment, on an average 10 percent per hour of the initial value. The hyperglycemia and acidosis were corrected by 2-12 hours of treatment. The deficiency of water and electrolytes, especially potassium, was treated with infusion from the beginnning, and the fluid balance was corrected within 12-16 hours. A severe fall in plasma potassium was never seen, but hypokalemia (less than 3.6mEg/I) was still present in some cases after 24 hours of treatment. One patient died on account of a large myocardial infarction, but otherwise the patients were restored to habitual condition in 1-4 days. The regimen was found to be simple, safe and effective in all cases, without risk of late hypoglycemia or severe hypokalemia. The study indicates, however, that the parenteral supply of potassium advocated previously, 12.5 mEq/hour, is not sufficient when the plasma potassium on admission is below 5.0mEq/I. In such cases it is recommended that the rate of potassium infusion is increased.
Collapse
|
27
|
Kamha A. Non Ketotic Hyperosmolar Hyperglycemia presenting as Epilepsia Partialis Continua. (An unusual presentation of a common disorder). Scott Med J 2008. [DOI: 10.1258/rsmsmj.53.4.10d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
We report a patient with epilepsia partialis continua (EPC) associated with non ketotic hyperosmolar hyperglycemia. EPC is uncommon presenting clinical finding during nonketotic hyperglycemia. This case was reported in Medical Intensive Care Unit (MICU) in Hamad Medical Corporation, Doha, Qatar.
Collapse
Affiliation(s)
- A Kamha
- Consultant Intensivist Physician. Head of Medical Intensive Care Unit. Hamad Medical Corporation
| |
Collapse
|
28
|
Mégarbane B, Deye N, Bloch V, Sonneville R, Collet C, Launay JM, Baud FJ. Intentional overdose with insulin: prognostic factors and toxicokinetic/toxicodynamic profiles. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2008; 11:R115. [PMID: 17963523 PMCID: PMC2556768 DOI: 10.1186/cc6168] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/31/2007] [Accepted: 10/28/2007] [Indexed: 08/29/2023]
Abstract
Introduction Prognostic factors in intentional insulin self-poisoning and the significance of plasma insulin levels are unclear. We therefore conducted this study to investigate prognostic factors in insulin poisoning, in relation to the value of plasma insulin concentration. Methods We conducted a prospective study, and used logistic regression to explore prognostic factors and modelling to investigate toxicokinetic/toxicodynamic relationships. Results Twenty-five patients (14 female and 11 male; median [25th to 75th percentiles] age 46 [36 to 58] years) were included. On presentation, the Glasgow Coma Scale score was 9 (4 to 14) and the capillary glucose concentration was 1.4 (1.1 to 2.3) mmol/l. The plasma insulin concentration was 197 (161 to 1,566) mIU/l and the cumulative amount of glucose infused was 301 (184 to 1,056) g. Four patients developed sequelae resulting in two deaths. Delay to therapy in excess of 6 hours (odds ratio 60.0, 95% confidence interval 2.9 to 1,236.7) and ventilation for longer than 48 hours (odds ratio 28.5, 95% confidence interval 1.9 to 420.6) were identified as independent prognostic factors. Toxicokinetic/toxicodynamic relationships between glucose infusion rates and insulin concentrations fit the maximum measured glucose infusion rate (Emax) model (Emax 29.5 [17.5 to 41.1] g/hour, concentration associated with the half-maximum glucose infusion rate [EC50] 46 [35 to 161] mIU/l, and R2 range 0.70 to 0.98; n = 6). Conclusion Intentional insulin overdose is rare. Assessment of prognosis relies on clinical findings. The observed plasma insulin EC50 is 46 mIU/l.
Collapse
Affiliation(s)
- Bruno Mégarbane
- Assistance Publique-Hôpitaux de Paris, Hôpital Lariboisière, Réanimation Médicale et Toxicologique, INSERM U705, CNRS, UMR 7157, Université Paris 7, 2 Rue Ambroise Paré, 75010, Paris, France.
| | | | | | | | | | | | | |
Collapse
|
29
|
Schäfer C, Gehrmann T, Richter L, Keitel V, Köhrer K, Häussinger D, Schliess F. Modulation of Gene Expression Profiles by Hyperosmolarity and Insulin. Cell Physiol Biochem 2008; 20:369-86. [PMID: 17762165 DOI: 10.1159/000107522] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/30/2007] [Indexed: 01/11/2023] Open
Abstract
Cell hydration changes play a key role in the regulation of cell function and critically affect insulin sensitivity of carbohydrate- and protein metabolism. Here, the modulation of gene expression profiles by hyperosmolarity and insulin was examined in H4IIE rat hepatoma cells by cDNA/oligonucleotiode array-, Northern- and Western blot analysis. Osmosensitive expression of the insulin-like growth factor binding protein Igfbp1, the multidrug resistance protein Mrp5 (Abcc5a) and cyclin D1 (Ccnd1) was established at the mRNA and protein level. Despite a hyperosmotic increase of cyclin D1 mRNA induction by insulin, the cyclin D1 protein expression was decreased by hyperosmolarity, suggesting a hyperosmotic interference with cyclin D1 mRNA translation. Hyperosmolarity at the mRNA level blunted the insulin response of betaine homocysteine-S-methyl transferase, the multidrug resistance proteins Mdr1a (Abcb1a) and 2 (Abcb4), the Igfbp 2 and 5, cyclin G1, dual specificity phosphatase Dusp1, signal transducers and activators of transcription Stat3 and 5, catalase and the bile salt export pump Bsep (Abcb11), whereas the insulin response was increased for Mrp5, cyclin D1 and the phosphoenolpyruvate carboxykinase. Insulin effects on the mRNA expression of the eukaryotic initiation factor 4E binding protein 4e-bp1, tubulin, gene 33, growth hormone receptor, keratin18, ornithine decarboxylase and heme oxygenase 1 were largely insensitive to hyperosmolarity. The data indicate that hyperosmolarity differentially modulates insulin sensitivity at the level of gene expression.
Collapse
Affiliation(s)
- Christine Schäfer
- Heinrich-Heine-University, Clinic for Gastroenterology, Hepatology, and Infectiology, Düsseldorf, Germany
| | | | | | | | | | | | | |
Collapse
|
30
|
Abstract
Saline should be used for fluid replacement rather than Hartmann's solution
Collapse
|
31
|
Savage MW, Kilvert A. ABCD guidelines for the management of hyperglycaemic emergencies in adults. ACTA ACUST UNITED AC 2006. [DOI: 10.1002/pdi.957] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
|
32
|
Abstract
Hyperglycaemic hyperosmolar syndrome is a major acute complication of decompensated diabetes mellitus. It represents the second most common aetiology of diabetic coma and is associated with excess mortality. It is characterised by severe hyperglycaemia, hyperosmolality and dehydration in the absence of significant ketosis, afflicting principally middle-aged-to-elderly patients. Early clinical diagnosis and prompt treatment, consisting of fluid replacement, insulin therapy, restoration of electrolyte disturbances and management of concurrent illnesses may improve the outcome. This review provides an outline of the diagnostic approach of patients with manifestations of hyperglycaemic hyperosmolar syndrome and discusses the contemporary therapeutic recommendations.
Collapse
Affiliation(s)
- Haralampos J Milionis
- Department of Internal Medicine, Medical School, University of Ioannina, 451 10 Ioannina, Greece.
| | | |
Collapse
|
33
|
Abstract
Diabetic ketoacidosis (DKA) is the most common hyperglycemic emergency in patients with diabetes mellitus. DKA most often occurs in patients with type 1 diabetes, but patients with type 2 diabetes are susceptible to DKA under stressful conditions, such as trauma, surgery, or infections. DKA is reported to be responsible for more than 100 000 hospital admissions per year in the US, and accounts for 4-9% of all hospital discharge summaries among patients with diabetes. Treatment of patients with DKA uses significant healthcare resources and accounts for 1 out of every 4 healthcare dollars spent on direct medical care for adult patients with type 1 diabetes in the US. Recent studies using standardized written guidelines for therapy have demonstrated a mortality rate of less than 5%, with higher mortality rates observed in elderly patients and those with concomitant life-threatening illnesses. Worldwide, infection is the most common precipitating cause for DKA, occurring in 30-50% of cases. Urinary tract infection and pneumonia account for the majority of infections. Other precipitating causes are intercurrent illnesses (i.e., surgery, trauma, myocardial ischemia, pancreatitis), psychological stress, and non-compliance with insulin therapy. The triad of uncontrolled hyperglycemia, metabolic acidosis and increased total body ketone concentration characterizes DKA. These metabolic derangements result from the combination of absolute or relative insulin deficiency and increased levels of counter-regulatory hormones (glucagon, catecholamines, cortisol, and growth hormone). Successful treatment of DKA requires frequent monitoring of patients, correction of hypovolemia and hyperglycemia, replacement of electrolyte losses, and careful search for the precipitating cause. Since the majority of DKA cases occur in patients with a known history of diabetes, this acute metabolic complication should be largely preventable through early detection, and by the education of patients, healthcare professionals, and the general public. The frequency of hospitalizations for DKA has been reduced following diabetes education programs, improved follow-up care, and access to medical advice. Novel approaches to patient education incorporating a variety of healthcare beliefs and socioeconomic issues are critical to an effective prevention program.
Collapse
Affiliation(s)
- Guillermo E Umpierrez
- Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee 38163, USA.
| | | |
Collapse
|
34
|
[Practice for insulin infusion in preterm infants]. Arch Pediatr 2005; 11:1054-9. [PMID: 15350994 DOI: 10.1016/j.arcped.2004.03.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2003] [Accepted: 03/04/2004] [Indexed: 10/26/2022]
Abstract
UNLABELLED Transient neonatal hyperglycemia is commonly observed during the first week of life in the preterm infants less than 30 weeks of gestational age. Continuous insulin infusion is an effective treatment in this situation. OBJECTIVE To ascertain how insulin is administered in different french neonatal intensive care units. MATERIAL AND METHODS We surveyed 49 neonatal intensive care units with a questionnaire. Response rate was 77.5% (38/49). RESULTS Thirty four of 38 neonatal intensive care units reported the use of insulin infusions in this setting. Glucose level indicating insulin therapy and the initial insulin doses were quite variable according to the different units (respectively 7-16.5 mmol/l and 0.01-0.1 U/kg/h). A range of minimal insulin concentrations was used (0.01-0.1 U/ml), 57% utilizing concentration between 0.05 and 0.2 U/ml. Flow rates below 0.3 ml/h were used at time by 76%. Albumin was rarely added. Fifty seven percent of the neonatal intensive care units took counter-measures such as preconditioning and flushing the tubing to control insulin loss due to adsorption. The counter-measures were differently applied. Despite these measures, hyperglycemia and insulin resistance were frequently observed (respectively 30% and 47%). The different practices are discussed according to the literature. CONCLUSION In order to deliver insulin reliably, we suggest an insulin delivery method for the preterm infants.
Collapse
|
35
|
Abstract
Diabetic ketoacidosis (DKA) is still a major contributor to morbidity and mortality in diabetes. The triad of hyperglycaemia, ketosis and acidosis can be diagnosed within a few minutes of the patient presenting, by measuring blood glucose and ketones using a meter, and venous blood pH on a blood gas analyser. Quantifying ketosis allows accurate distinction between simple hyperglycaemia and metabolic decompensation. We review the management of DKA, and the emerging role of near-patient testing in diagnosing ketosis and monitoring its resolution.
Collapse
Affiliation(s)
- T M Wallace
- Oxford Centre for Diabetes, Endocrinology and Metabolism, The Churchill Hospital, Old Road, Oxford OX3 7LJ.
| | | |
Collapse
|
36
|
Umpierrez GE, Latif K, Stoever J, Cuervo R, Park L, Freire AX, E Kitabchi A. Efficacy of subcutaneous insulin lispro versus continuous intravenous regular insulin for the treatment of patients with diabetic ketoacidosis. Am J Med 2004; 117:291-6. [PMID: 15336577 DOI: 10.1016/j.amjmed.2004.05.010] [Citation(s) in RCA: 132] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2003] [Revised: 05/21/2004] [Accepted: 05/21/2004] [Indexed: 12/21/2022]
Abstract
PURPOSE To compare the efficacy and safety of subcutaneous insulin lispro with that of a standard low-dose intravenous infusion protocol of regular insulin in patients with uncomplicated diabetic ketoacidosis. METHODS In this prospective, randomized open trial, 20 patients treated with subcutaneous insulin lispro were managed in regular medicine wards (n=10) or an intermediate care unit (n=10), while 20 patients treated with the intravenous protocol were managed in the intensive care unit. Patients treated with subcutaneous lispro received an initial injection of 0.3 unit/kg followed by 0.1 unit/kg/h until correction of hyperglycemia (blood glucose levels <250 mg/dL), followed by 0.05 to 0.1 unit/kg/h until resolution of diabetic ketoacidosis (pH > or =7.3, bicarbonate > or =18 mEq/L). Patients treated with intravenous regular insulin received an initial bolus of 0.1 unit/kg, followed by an infusion of 0.1 unit/kg/h until correction of hyperglycemia, then 0.05 to 0.1 unit/kg/h until resolution of diabetic ketoacidosis. RESULTS Mean (+/- SD) admission biochemical parameters in patients treated with subcutaneous lispro (glucose: 674 +/- 154 mg/dL; bicarbonate: 9.2 +/- 4 mEq/L; pH: 7.17 +/- 0.10) were similar to values in patients treated with intravenous insulin (glucose: 611 +/- 264 mg/dL; bicarbonate: 10.6 +/- 4 mEq/L; pH: 7.19 +/- 0.08). The duration of treatment until correction of hyperglycemia (7 +/- 3 hours vs. 7 +/- 2 hours) and resolution of ketoacidosis (10 +/- 3 hours vs. 11 +/- 4 hours) in patients treated with subcutaneous lispro was not different than in patients treated with intravenous regular insulin. There were no deaths in either group, and there were no differences in the length of hospital stay, amount of insulin until resolution of diabetic ketoacidosis, or in the rate of hypoglycemia between treatment groups. Treatment of diabetic ketoacidosis in the intensive care unit was associated with 39% higher hospitalization charges than was treatment with subcutaneous lispro in a non-intensive care setting ($14,429 +/- $5243 vs. $8801 +/- $5549, P <0.01). CONCLUSION Treatment of adult patients who have uncomplicated diabetic ketoacidosis with subcutaneous lispro every hour in a non-intensive care setting may be safe and more cost-effective than treatment with intravenous regular insulin in the intensive care unit.
Collapse
Affiliation(s)
- Guillermo E Umpierrez
- Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA.
| | | | | | | | | | | | | |
Collapse
|
37
|
Fukao T, Lopaschuk GD, Mitchell GA. Pathways and control of ketone body metabolism: on the fringe of lipid biochemistry. Prostaglandins Leukot Essent Fatty Acids 2004; 70:243-51. [PMID: 14769483 DOI: 10.1016/j.plefa.2003.11.001] [Citation(s) in RCA: 261] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Ketone bodies become major body fuels during fasting and consumption of a high-fat, low-carbohydrate (ketogenic) diet. Hyperketonemia is associated with potential health benefits. Ketone body synthesis (ketogenesis) is the last recognizable step of lipid energy metabolism, a pathway that links dietary lipids and adipose triglycerides to the Krebs cycle and respiratory chain and has three highly regulated control points: (1) adipocyte lipolysis, (2) mitochondrial fatty acids entry, controlled by the inhibition of carnitine palmityl transferase I by malonyl coenzyme A (CoA) and (3) mitochondrial 3-hydroxy-3-methylglutaryl CoA synthase, which catalyzes the irreversible first step of ketone body synthesis. Each step is suppressed by an elevated circulating insulin level or insulin/glucagon ratio. The utilization of ketone bodies (ketolysis) also determines circulating ketone body levels. Consideration of ketone body metabolism reveals the mechanisms underlying the extreme fragility of dietary ketosis to carbohydrate intake and highlights areas for further study.
Collapse
Affiliation(s)
- Toshiyuki Fukao
- Department of Pediatrics, Gifu University School of Medicine, Gifu 500, Japan
| | | | | |
Collapse
|
38
|
Lim SCB, Roberts MJ, Paech MJ, Peng L, Jones A. Stability of Insulin Aspart in Normal Saline Infusion. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2004. [DOI: 10.1002/jppr200434111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
39
|
Clement S, Braithwaite SS, Magee MF, Ahmann A, Smith EP, Schafer RG, Hirsch IB, Hirsh IB. Management of diabetes and hyperglycemia in hospitals. Diabetes Care 2004; 27:553-91. [PMID: 14747243 DOI: 10.2337/diacare.27.2.553] [Citation(s) in RCA: 793] [Impact Index Per Article: 39.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Stephen Clement
- Department of Endocrinology, Georgetown University Hospital, Washington, DC 20007, USA.
| | | | | | | | | | | | | | | |
Collapse
|
40
|
Abstract
Perturbations of cell hydration as provoked by changes in ambient osmolarity or under isoosmotic conditions by hormones, second messengers, intracellular substrate accumulation, or reactive oxygen intermediates critically contribute to the physiological regulation of cell function. In general an increase in cell hydration stimulates anabolic metabolism and proliferation and provides cytoprotection, whereas cellular dehydration leads to a catabolic situation and sensitizes cells to apoptotic stimuli. Insulin produces cell swelling by inducing a net K+ and Na+ accumulation inside the cell, which results from a concerted activation of Na+/H+ exchange, Na+/K+/2Cl- symport, and the Na+/K(+)-ATPase. In the liver, insulin-induced cell swelling is critical for stimulation of glycogen and protein synthesis as well as inhibition of autophagic proteolysis. These insulin effects can largely be mimicked by hypoosmotic cell swelling, pointing to a role of cell swelling as a trigger of signal transduction. This article discusses insulin-induced signal transduction upstream of swelling and introduces the hypothesis that cell swelling as a signal amplifyer represents an essential component in insulin signaling, which contributes to the full response to insulin at the level of signal transduction and function. Cellular dehydration impairs insulin signaling and may be a major cause of insulin resistance, which develops in systemic hyperosmolarity, nutrient deprivation, uremia, oxidative challenges, and unbalanced production of insulin-counteracting hormones. Hydration changes affect cell functions at multiple levels (such as transcriptom, proteom, phosphoproteom, and the metabolom) and a system biological approach may allow us to develop a more holistic view on the hydration dependence of insulin signaling in the future.
Collapse
Affiliation(s)
- Freimut Schliess
- Clinic for Gastroenterology, Hepatology and Infectiology, Heinrich-Heine-University, Düsseldorf, Germany
| | | |
Collapse
|
41
|
Magee MF, Bhatt BA. Management of decompensated diabetes. Diabetic ketoacidosis and hyperglycemic hyperosmolar syndrome. Crit Care Clin 2001; 17:75-106. [PMID: 11219236 DOI: 10.1016/s0749-0704(05)70153-6] [Citation(s) in RCA: 76] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
DKA and HHS represent two extremes in the spectrum of decompensated diabetes mellitus. Their pathogenesis is related to absolute or relative deficiency in insulin levels and elevations in insulin counterregulatory hormones that lead to altered metabolism of carbohydrate, protein, and fat and varying degrees of osmotic diuresis and dehydration, ketosis, and acidosis. In DKA, insulin deficiency and ketoacidosis are the prominent features of the clinical presentation, and insulin therapy is the cornerstone of therapy. In HHS, hyperglycemia, osmotic diuresis, and dehydration are the prominent features, and fluid replacement is the cornerstone of therapy. As many as one-third of patients may have mixed features of both DKA and HHS. Because the three-pronged approach to therapy for either DKA or HHS consists of fluid administration, intravenous insulin infusion, and electrolyte replacement, mixed cases are managed using the same approach. The therapeutic regimen is tailored according to the prominent clinical features present. In adult patients with mixed features, fluids may be administered more rapidly than they would be in younger patients, or in patients with DKA alone, because the risk for fatal cerebral edema in adults is low and the consequences of undertreatment include vascular occlusion and increased mortality. In younger patients with mixed features, rapid correction of metabolic abnormalities and, consequently, of hyperosmolarity by administration of hypotonic fluids and insulin should be avoided to decrease the risk for precipitating cerebral edema. In addition, if ketoacidosis has been a prominent feature in a mixed case, the patient may have type 1 diabetes with no residual pancreatic islet beta cell secretion and may subsequently need ongoing, life-long insulin therapy after resolution of the acute episode of decompensated diabetes. ICU admission is indicated in the management of DKA, HHS, and mixed cases in the presence of cardiovascular instability, inability to protect the airway, obtundation, the presence of acute abdominal signs or symptoms suggestive of acute gastric dilatation, or if there is not adequate capacity on the floor unit to administer the intravenous insulin infusion and to provide the frequent and necessary monitoring that must accompany its use.
Collapse
Affiliation(s)
- M F Magee
- MedStar Diabetes Institute, Washington Hospital Center, Washington, DC, USA.
| | | |
Collapse
|
42
|
Shibutani Y, Ogawa C. Suicidal insulin overdose in a type 1 diabetic patient: relation of serum insulin concentrations to the duration of hypoglycemia. J Diabetes Complications 2000; 14:60-2. [PMID: 10925068 DOI: 10.1016/s1056-8727(00)00057-x] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
We present a case of a 31-year-old Type 1 diabetic woman who self-administered 2400 units of insulin mixture (70% NPH human insulin and 30% Regular human insulin) as a suicidal attempt. The subsequent hypoglycemia was prolonged probably due to delayed absorption of the subcutaneous insulin, but it was not very difficult to control despite the administration of large amounts of insulin. Although the estimated serum insulin level was not well correlated with the severity of hypoglycemia, the hypoglycemia subsided when the serum insulin level returned to the physiological level. Therefore, the study of insulin pharmacokinetics after insulin overdose may be useful to know the necessary duration of exogenous glucose administration required to manage the medical emergency of severe insulin intoxication in future cases.
Collapse
Affiliation(s)
- Y Shibutani
- Division of Endocrinology, Department of Internal Medicine, Nishi-Kobe Medical Center, 7-1, Kouji-dai 5-chome, Nishi-ku, 651-2273, Kobe, Japan
| | | |
Collapse
|
43
|
Abstract
Diabetic ketoacidosis (DKA) is a true pediatric and medical emergency. Diagnosis should be entertained and confirmed within 30 min of presentation. Any delay in making the diagnosis or instituting fluid and electrolyte correction is likely to increase morbidity and mortality. Slow and careful monitoring and correction of water, sodium and potassium levels should decrease DKA-associated problems with either continuous intravenous low-dose insulin or intramuscular insulin protocols designed to slowly bring the hyperglycemic and hyperosmotic state towards normal homeostasis. Special attention should be paid to potassium replenishment. Most patients do not require bicarbonate replacement. Cerebral edema, when it occurs, is associated with an approximately 50% morbidity and mortality; therefore, all attempts should be made at early recognition and prevention since treatment is less than ideal. Recurrent ketoacidosis is often related to omitted insulin and major psychosocial turmoil in the family, such as depression substance abuse, physical and/or sexual abuse. Prevention of recurrent DKA remains a major challenge for diabetologists and involves detailed assessment of family psychodynamics plus responsibility for home monitoring and insulin administration by a mature adult. Sick day guidelines should be taught and reviewed frequently in an effort to decrease ketoacidosis and metabolic decompensation during episodes of intercurrent illness.
Collapse
Affiliation(s)
- S J Brink
- New England Diabetes and Endocrinology Center, Waltham, MA 02154-1136, USA
| |
Collapse
|
44
|
Umpierrez GE, Khajavi M, Kitabchi AE. Review: diabetic ketoacidosis and hyperglycemic hyperosmolar nonketotic syndrome. Am J Med Sci 1996; 311:225-33. [PMID: 8615398 DOI: 10.1097/00000441-199605000-00006] [Citation(s) in RCA: 49] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- G E Umpierrez
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia 30303, USA
| | | | | |
Collapse
|
45
|
umpierrez GE, Khajavi M, Kitabchi AE. Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar Nonketotic Syndrome. Am J Med Sci 1996. [DOI: 10.1016/s0002-9629(15)41700-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
|
46
|
Hirai T, Minatogawa Y, Hassan AM, Kido R. Metabolic inter-organ relations by exercise of fed rat: carbohydrates, ketone body, and nitrogen compounds in splanchnic vessels. Physiol Behav 1995; 57:515-22. [PMID: 7753890 DOI: 10.1016/0031-9384(94)00293-e] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Fed rats were exercised until exhaustion by almost 65% VO2max on a treadmill. In 2.5 min after the exercise, blood was collected from various vessels of the splanchnic bed. Metabolites, glucose, lactate, ketone body, and nitrogencompounds in the plasma, were measured. Glucose excretion from the liver was increased by exercise, but was not significant. The absorption by the kidney decreased to 30% by exercise. Lactate was highly absorbed by the kidney, lower limbs, and digestive tract by exercise. Exercise caused a 200-300% increase of the plasma beta-hydroxybutyrate, but the absorption by the kidney and the lower limbs was decreased. These data suggest that glucose is a good carbon source for the recovery, and that lactate is more useful than glucose, but ketone body is less effective at a very early recovery phase under fed condition. Amino acid balances in each organ except digestive tract were positive showing anabolic conditions of these organs even after exhaustive exercise at fed condition. Most amino acid concentrations in the plasma tended to decrease to 60-90% by exercise. Amino acids were excreted from the digestive tract, and were eventually absorbed by the liver in both rested and exercised rat. The digestive tract, therefore, seems to be a primary amino acids pool to supply them to the liver during the inter meal. Urea excretion from the liver was more than the absorbed ammonia showing that active deamination from amino acids was carrying on. The resulted carbon skeletons of the amino acids might be used for the gluconeogenesis in the liver.
Collapse
Affiliation(s)
- T Hirai
- Faculty of Health and Sport Sciences, Osaka University, Machikaneyama, Japan
| | | | | | | |
Collapse
|
47
|
Abstract
Physiological concentrations of oleic acid inhibited C5a-induced myeloperoxidase release from neutrophils. The inhibition occurred promptly following the addition of oleic acid, was dose-dependent and saturable, and was greater at low concentrations of C5a. Kinetic analysis of the curve for 1/myeloperoxidase release against 1/[C5a] in the presence of oleic acid, was compatible with a cooperative pattern of interaction. The inhibitory effect persisted after repeated washings of cells preincubated with oleic acid. The effect of oleic acid was not specific for C5a-induced neutrophil activation; oleic acid also inhibited myeloperoxidase release induced by the Ca2+ ionophore A-23187, as well as zymosan activated serum-induced chemotaxis. In experiments designed to localize the site of action of oleic acid on neutrophil activation, an intracellular oleic acid-binding protein M(r) = 13,000) was isolated. The results suggest that acute changes in plasma fatty acid levels may have significant effects on neutrophil function under physiological conditions.
Collapse
|
48
|
Pühringer F, Mitterschiffthaler G, Hagn C, Kieselbach G, Göttinger W, Benzer A. Der diabetische Patient in der ophthalmologischen Chirurgie. SPEKTRUM DER AUGENHEILKUNDE 1994. [DOI: 10.1007/bf03163745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
|
49
|
Jolobe OM. Characteristics of diabetic ketoacidosis in older patients. J Am Geriatr Soc 1993; 41:888. [PMID: 8340572 DOI: 10.1111/j.1532-5415.1993.tb06193.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
|
50
|
|