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Stamatiades GA, Galbiati F, Fitzgerald AC, McDonnell ME, Lassey SC, Palermo NE. Diabetes Mellitus Type 1 Presenting in the Setting of Diabetic Ketoacidosis and Acute SARS-CoV-2 Infection in Pregnancy. AACE Clin Case Rep 2023; 9:S2376-0605(23)00091-3. [PMID: 37363439 PMCID: PMC10102535 DOI: 10.1016/j.aace.2023.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 03/10/2023] [Accepted: 04/10/2023] [Indexed: 06/28/2023] Open
Abstract
Background/Objective Diabetic ketoacidosis (DKA) during pregnancy is an obstetric emergency associated with a higher rate of maternofetal morbidity and mortality. Pregnancy itself is a ketosis-prone state and several unique mechanisms predispose to the development of insulin resistance, which can be further exacerbated by acute stressors such as infection. Thus, pregnant patients who additionally contract COVID-19 may be at an even higher risk of development of DKA. Case Report A 32-year-old patient, with no prior history of impaired glucose tolerance, presented at 27 weeks of gestation with a 3-day history of shortness of breath, congestion, loss of taste and smell, polyuria, and polydipsia. Biochemical evaluation was consistent with DKA. Subsequently, she was diagnosed with acute SARS-CoV-2 infection. Treatment included intravenous hydration, electrolyte replacement, and insulin infusion. Postpartum phenotypic evaluation confirmed autoimmune diabetes (positive GAD-65 and zinc T8 antibodies) with residual β-cell function. Six months postpartum, glycemic control remains at goal with basal- bolus insulin regimen. Discussion This case describes the peculiar ability of SARS-CoV-2 infection to potentially rouse autoimmunity and how COVID-19 and DKA in pregnancy can be particularly challenging given the risk of significant maternal and fetal morbidity and mortality. Conclusion Prompt diagnosis and evaluation of DKA in pregnancy as well as a higher level of suspicion is needed in the setting of SARS-CoV-2 infection. Additionally, this case depicts the need for closely monitoring the postpartum period for patients at risk of autoimmune disease, which may have been blunted in pregnancy.
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Affiliation(s)
- George A Stamatiades
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Francesca Galbiati
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Marie E McDonnell
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sarah C Lassey
- Division of Maternal-Fetal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Nadine E Palermo
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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McDonnell ME, Garg R, Gopalakrishnan G, Mitri J, Weinstock RS, Greenfield M, Katta S, Lebastchi J, Palermo NE, Radhakrishnan R, Westcott GP, Johnson M, Simonson DC. Glycemic Gap Predicts Mortality in a Large Multicenter Cohort Hospitalized With COVID-19. J Clin Endocrinol Metab 2023; 108:718-725. [PMID: 36217580 PMCID: PMC9619706 DOI: 10.1210/clinem/dgac587] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 09/27/2022] [Indexed: 11/19/2022]
Abstract
CONTEXT Diabetes or hyperglycemia at admission are established risk factors for adverse outcomes during hospitalization for COVID-19, but the impact of prior glycemic control is not clear. OBJECTIVE We aimed to examine the associations between admission variables, including glycemic gap, and adverse clinical outcomes in patients hospitalized with COVID-19 infection. METHODS We examined the relationship between clinical predictors, including acute and chronic glycemia, and clinical outcomes, including intensive care unit (ICU) admission, mechanical ventilation (MV), and mortality among 1786 individuals with diabetes or hyperglycemia (glucose > 10 mmol/L twice in 24 hours) who were admitted from March 2020 through February 2021 with COVID-19 infection at 5 university hospitals in the eastern United States. RESULTS The cohort was 51.3% male, 53.3% White, 18.8% Black, 29.0% Hispanic, with age = 65.6 ± 14.4 years, BMI = 31.5 ± 7.9 kg/m2, glucose = 12.0 ± 7.5 mmol/L [216 ± 135 mg/dL], and HbA1c = 8.07% ± 2.25%. During hospitalization, 38.9% were admitted to the ICU, 22.9% received MV, and 10.6% died. Age (P < 0.001) and admission glucose (P = 0.014) but not HbA1c were associated with increased risk of mortality. Glycemic gap, defined as admission glucose minus estimated average glucose based on HbA1c, was a stronger predictor of mortality than either admission glucose or HbA1c alone (OR = 1.040 [95% CI: 1.019, 1.061] per mmol/L, P < 0.001). In an adjusted multivariable model, glycemic gap, age, BMI, and diabetic ketoacidosis on admission were associated with increased mortality, while higher estimated glomerular filtration rate (eGFR) and use of any diabetes medication were associated with lower mortality (P < 0.001). CONCLUSION Relative hyperglycemia, as measured by the admission glycemic gap, is an important marker of mortality risk in COVID-19.
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Affiliation(s)
- Marie E McDonnell
- Corresponding Author: Marie E. McDonnell, M.D. Division of Endocrinology, Diabetes and Hypertension Brigham and Women’s Hospital 221 Longwood Avenue Boston, MA 02115 E-mail: phone: 617-732-5693
| | - Rajesh Garg
- University of Miami, Miller School of Medicine, Miami, FL
| | - Geetha Gopalakrishnan
- Rhode Island Hospital, Providence, RI
- Warren Alpert Medical School of Brown University, Providence, RI
| | - Joanna Mitri
- Harvard Medical School, Boston, MA
- Joslin Diabetes Center, Boston, MA
- Beth Israel-Deaconess Medical Center, Boston, MA
| | - Ruth S Weinstock
- State University of New York Upstate Medical University, Syracuse, NY
| | | | - Sai Katta
- State University of New York Upstate Medical University, Syracuse, NY
| | - Jasmin Lebastchi
- Rhode Island Hospital, Providence, RI
- Warren Alpert Medical School of Brown University, Providence, RI
| | - Nadine E Palermo
- Brigham and Women’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | | | - Gregory P Westcott
- Harvard Medical School, Boston, MA
- Beth Israel-Deaconess Medical Center, Boston, MA
| | | | - Donald C Simonson
- Brigham and Women’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
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Vitale RJ, Valtis YK, McDonnell ME, Palermo NE, Fisher NDL. Euglycemic Diabetic Ketoacidosis With COVID-19 Infection in Patients With Type 2 Diabetes Taking SGLT2 Inhibitors. AACE Clin Case Rep 2020; 7:10-13. [PMID: 33521255 PMCID: PMC7833657 DOI: 10.1016/j.aace.2020.11.019] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Objective Diabetes mellitus is associated with poor outcomes in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Diabetic ketoacidosis (DKA) has also been reported to occur with this virus. A cluster of cases of euglycemic DKA (euDKA) was identified in patients with type 2 diabetes mellitus using sodium-glucose cotransporter-2 inhibitors (SGLT2is) who developed SARS-CoV-2 infection. Methods The cases were identified by the authors while providing clinical care, and details were collected. Results Five cases of euDKA, presenting with glucose levels <300 mg/dL, were identified over the course of 2 months by the endocrinology consult service. All patients had a history of type 2 diabetes mellitus with no known history of DKA. All were taking SGLT2is. Oral antihyperglycemic medications were stopped for all patients on admission. All received intravenous insulin infusion to treat DKA before being transitioned to a subcutaneous insulin regimen. SGLT2i use was discontinued for all patients who were discharged. Conclusion EuDKA has been seen in the setting of acute illness in patients using SGLT2is, but this cluster of cases suggests that there is a specific association with SARS-CoV-2 infection. In addition to the known risk of euDKA with SGLT2i use, coronavirus disease 2019-specific mechanisms may include a direct toxic effect of the virus on the pancreatic islets, an accelerated inflammatory response promoting ketosis, and the diuretic effect of SGLT2i in conjunction with anorexia and vomiting. It is crucial to counsel patients to stop SGLT2is when sick, especially if SARS-CoV-2 infection is suspected.
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Affiliation(s)
- Rebecca J Vitale
- Division of Endocrinology, Diabetes, and Hypertension, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Yannis K Valtis
- Department of Medicine, Brigham and Women's Hospital, Medical Residency Office, Boston, Massachusetts
| | - Marie E McDonnell
- Division of Endocrinology, Diabetes, and Hypertension, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Nadine E Palermo
- Division of Endocrinology, Diabetes, and Hypertension, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Naomi D L Fisher
- Division of Endocrinology, Diabetes, and Hypertension, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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Affiliation(s)
- Danica M Vodopivec
- From the Department of Medicine, Section of Endocrinology, Diabetes, and Nutrition, Boston University Medical Center, Boston
| | - Dylan D Thomas
- From the Department of Medicine, Section of Endocrinology, Diabetes, and Nutrition, Boston University Medical Center, Boston
| | - Nadine E Palermo
- From the Department of Medicine, Section of Endocrinology, Diabetes, and Nutrition, Boston University Medical Center, Boston
| | - Devin W Steenkamp
- From the Department of Medicine, Section of Endocrinology, Diabetes, and Nutrition, Boston University Medical Center, Boston
| | - Stephanie L Lee
- From the Department of Medicine, Section of Endocrinology, Diabetes, and Nutrition, Boston University Medical Center, Boston
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Galindo RJ, Umpierrez GE, Rushakoff RJ, Basu A, Lohnes S, Nichols JH, Spanakis EK, Espinoza J, Palermo NE, Awadjie DG, Bak L, Buckingham B, Cook CB, Freckmann G, Heinemann L, Hovorka R, Mathioudakis N, Newman T, O’Neal DN, Rickert M, Sacks DB, Seley JJ, Wallia A, Shang T, Zhang JY, Han J, Klonoff DC. Continuous Glucose Monitors and Automated Insulin Dosing Systems in the Hospital Consensus Guideline. J Diabetes Sci Technol 2020; 14:1035-1064. [PMID: 32985262 PMCID: PMC7645140 DOI: 10.1177/1932296820954163] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
This article is the work product of the Continuous Glucose Monitor and Automated Insulin Dosing Systems in the Hospital Consensus Guideline Panel, which was organized by Diabetes Technology Society and met virtually on April 23, 2020. The guideline panel consisted of 24 international experts in the use of continuous glucose monitors (CGMs) and automated insulin dosing (AID) systems representing adult endocrinology, pediatric endocrinology, obstetrics and gynecology, advanced practice nursing, diabetes care and education, clinical chemistry, bioengineering, and product liability law. The panelists reviewed the medical literature pertaining to five topics: (1) continuation of home CGMs after hospitalization, (2) initiation of CGMs in the hospital, (3) continuation of AID systems in the hospital, (4) logistics and hands-on care of hospitalized patients using CGMs and AID systems, and (5) data management of CGMs and AID systems in the hospital. The panelists then developed three types of recommendations for each topic, including clinical practice (to use the technology optimally), research (to improve the safety and effectiveness of the technology), and hospital policies (to build an environment for facilitating use of these devices) for each of the five topics. The panelists voted on 78 proposed recommendations. Based on the panel vote, 77 recommendations were classified as either strong or mild. One recommendation failed to reach consensus. Additional research is needed on CGMs and AID systems in the hospital setting regarding device accuracy, practices for deployment, data management, and achievable outcomes. This guideline is intended to support these technologies for the management of hospitalized patients with diabetes.
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Affiliation(s)
| | | | | | - Ananda Basu
- University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Suzanne Lohnes
- University of California San Diego Medical Center, La Jolla, CA, USA
| | | | - Elias K. Spanakis
- University of Maryland School of Medicine, Baltimore, MD, USA
- Division of Endocrinology, Baltimore Veterans Affairs Medical Center, MD, USA
| | | | - Nadine E. Palermo
- Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | | | | | | | | | | | | | | | | | - Tonya Newman
- Neal, Gerber and Eisenberg LLP, Chicago, IL, USA
| | - David N. O’Neal
- University of Melbourne Department of Medicine, St. Vincent’s Hospital, Fitzroy, Victoria, Australia
| | | | | | | | - Amisha Wallia
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Trisha Shang
- Diabetes Technology Society, Burlingame, CA, USA
| | | | - Julia Han
- Diabetes Technology Society, Burlingame, CA, USA
| | - David C. Klonoff
- Mills-Peninsula Medical Center, San Mateo, CA, USA
- David C. Klonoff, MD, FACP, FRCP (Edin), Fellow AIMBE, Mills-Peninsula Medical Center, 100 South San Mateo Drive Room 5147, San Mateo, CA 94401, USA.
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Abstract
CONTEXT While individuals with diabetes appear to be at similar risk for SARS-CoV-2 infection to those without diabetes, they are more likely to suffer severe consequences, including death. Diabetic ketoacidosis (DKA) is a common and potentially lethal acute complication of diabetes arising from a relative insulin deficiency, which occurs more often in those with type 1 diabetes and in the setting of moderate to severe illness. Early reports indicate that among patients with pre-existing diabetes, DKA may be a common complication of severe COVID-19 and a poor prognostic sign. CASE DESCRIPTION This clinical perspective explores the key elements of caring for individuals with DKA during the COVID-19 pandemic through 2 cases. Topics addressed include diagnosis, triage, and the fundamental principles of treatment with a focus on the importance of characterizing DKA severity and medical complexity to determine the best approach. CONCLUSIONS As discussed, some tenets of DKA management may require flexibility in the setting of COVID-19 due to important public health goals, such as preventing transmission to highest risk individuals, reducing healthcare worker exposure to infected patients, and preserving personal protective equipment. Evidence for alternative treatment strategies is explored, with special attention placed on treatment options that may be more relevant during the pandemic, including use of subcutaneous insulin therapy. Finally, DKA is often a preventable condition. We include evidence-based strategies and guidance designed to empower clinicians and patients to avoid this serious complication when possible.
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Affiliation(s)
- Nadine E Palermo
- Brigham and Women’s Hospital and Harvard Medical School, Division of Endocrinology, Diabetes and Hypertension, Boston, Massachusetts
| | - Archana R Sadhu
- Houston Methodist Hospital and Weill Cornell Medical College, Houston, Texas
| | - Marie E McDonnell
- Brigham and Women’s Hospital and Harvard Medical School, Division of Endocrinology, Diabetes and Hypertension, Boston, Massachusetts
- Correspondence and Reprint Requests: Marie E. McDonnell, MD, Director, Brigham and Women’s Hospital Diabetes Program, Division of Endocrinology, Diabetes and Hypertension, Brigham and Women’s Hospital, 221 Longwood Avenue, Boston, MA 02115, USA. E-mail:
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Abstract
PURPOSE OF REVIEW To assess evidence to date for use of non-insulin agents in treatment of gestational diabetes mellitus. RECENT FINDINGS There has been increasing interest in the use of non-insulin agents, primarily metformin and glyburide (which both cross the placenta). Metformin has been associated with less maternal weight gain; however, recent studies have shown a trend toward increased weight in offspring exposed to metformin in utero. Glyburide has been associated with increased neonatal hypoglycemia. Glycemic control during pregnancy is essential to optimize both maternal and fetal outcomes. There are a myriad of factors to consider when designing treatment programs including patient preference, phenotype, and glucose patterns. While insulin is typically recommended as first-line, some women refuse or cannot afford insulin and in those cases, non-insulin agents may be used. Further studies are needed to assess treatment in pregnancy, perinatal outcomes, and particularly long-term metabolic profiles in mothers and offspring.
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Affiliation(s)
- Rachel A Blair
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Harvard Medical School, 221 Longwood Avenue, Boston, MA, 02115, USA
| | - Emily A Rosenberg
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Harvard Medical School, 221 Longwood Avenue, Boston, MA, 02115, USA
| | - Nadine E Palermo
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Harvard Medical School, 221 Longwood Avenue, Boston, MA, 02115, USA.
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Palermo NE, Garg R. Reply to the Letter by M.S. Raghuraman Regarding "Perioperative Management of Diabetes Mellitus: Novel Approaches". Curr Diab Rep 2019; 19:87. [PMID: 31468189 DOI: 10.1007/s11892-019-1227-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Nadine E Palermo
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Harvard Medical School, 221 Longwood Avenue, Suite 381, Boston, MA, 02115, USA
| | - Rajesh Garg
- Comprehensive Diabetes Center, Division of Endocrinology, Diabetes and Metabolism, University of Miami, Miller School of Medicine, 5555 Ponce de Leon Blvd, Coral Gables, FL, 33145, USA.
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Shirvani A, Palermo NE, Holick MF. Man of Steel Syndrome: Silicone and Mineral Oil Injections With Associated Hypercalcemia, Hypophosphatemia, and Proximal Muscle Weakness. JBMR Plus 2019; 3:e10208. [PMID: 31687644 PMCID: PMC6820462 DOI: 10.1002/jbm4.10208] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 05/02/2019] [Accepted: 05/25/2019] [Indexed: 11/10/2022] Open
Abstract
Silicone/mineral oil‐induced granulomas have been described as an inflammatory granulomatous response when silicone/mineral oil is injected for cosmetic purposes. These sclerosing granulomas can lead to hypercalcemia. Here we present a 33‐year‐old man with hypercalcemia, hypophosphatemia, progressively worsening fatigue, severe proximal muscle weakness, and depression. He had an athletic build with increased muscle bulk and several areas of indurated, nontender, firm, well‐circumscribed lesions in the subcutaneous tissue of his anterior pectoralis, triceps, and biceps bilaterally because of injecting himself with silicone/mineral oil‐based product into his muscles. Sclerosing granulomas were diagnosed on the MRI. He had extremely low or undetectable serum levels of 25‐hydroxyvitamin D [25(OH)D], and persistently elevated serum levels of 1,25‐dihydroxyvitamin D [1,25(OH)2D] and calcium. He developed hypophosphatemia associated with elevated levels of fibroblast growth factor 23 (FGF‐23) and severe proximal muscle weakness. Treatment with systemic steroids, furosemide, calcitonin, ketoconazole, and denosumab resulted in a significant decrease in his serum calcium, but with minimal impact on his hypophosphatemia and fatigue.Correcting his severe vitamin D deficiency with small doses of vitamin D and raising his blood level of 25(OH)D from undetectable to 10 ng/mL without significantly affecting his serum calcium or phosphate was effective in reversing his severe proximal muscle weakness, permitting him to lift his head and to be free of his wheelchair. Although measurement of the 1,25(OH)2D level is not mandatory in all cases of hypercalcemia, it is indicated in a patient who has low serum PTH levels. Clinicians need to be aware that vitamin D deficiency can cause severe proximal muscle weakness such that the patient is unable to lift his head from his chest or ambulate. This may lead to a psychiatric disorder misdiagnosis. © 2019 The Authors. JBMR Plus is published by Wiley Periodicals, Inc. on behalf of the American Society for Bone and Mineral Research.
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Affiliation(s)
- Arash Shirvani
- Section of Endocrinology, Diabetes & Nutrition, Department of Medicine, Vitamin D, Skin, and Bone Research Laboratory Boston University School of Medicine (BUSM) Boston MA USA
| | - Nadine E Palermo
- Division of Endocrinology Diabetes and Hypertension, Brigham and Women's Hospital, Harvard Medical School Boston MA USA
| | - Michael F Holick
- Section of Endocrinology, Diabetes & Nutrition, Department of Medicine, Vitamin D, Skin, and Bone Research Laboratory Boston University School of Medicine (BUSM) Boston MA USA
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Abstract
PURPOSE OF REVIEW Several studies have demonstrated the benefits of glycemic control in the perioperative period and there is ongoing interest in development of systematic approaches to achieving glycemic control. This review discusses currently available data and proposes a new approach to the management of hyperglycemia in the perioperative period. RECENT FINDINGS In a recent study, we demonstrated that early preoperative identification of patients with poorly controlled diabetes and proactive treatment through various phases of surgery improves glycemic control, lowers the risk of surgical complications, and decreases the length of hospital stay. Implementation of a perioperative diabetes program that systematically identifies and treats patients with poor glycemic control early in the preoperative period is feasible and improves clinical care of patients undergoing elective surgery.
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Affiliation(s)
- Nadine E Palermo
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Harvard Medical School, 221 Longwood Avenue, Suite 381, Boston, MA, 02115, USA
| | - Rajesh Garg
- Comprehensive Diabetes Center, Miller School of Medicine, University of Miami, 5555 Ponce de Leon Blvd, Coral Gables, FL, 33145, USA.
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Blair RA, Palermo NE, Modzelewski KL, Alexanian SM, Baker WE, Simonson DC, McDonnell ME. REDUCED IMPACT OF DIABETES CLINIC REFERRAL ON HIGH-FREQUENCY EMERGENCY DEPARTMENT USERS. Endocr Pract 2018; 24:1043-1050. [PMID: 30289310 DOI: 10.4158/ep-2018-0161] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The patterns of emergency department (ED) visits in patients with diabetes are not well understood. The Emergency Department Diabetes Rapid-referral Program (EDRP) allows direct booking of ED patients presenting with urgent diabetes needs into a diabetes specialty clinic within 1 day of ED discharge. The objective of this secondary analysis was to examine characteristics of patients with diabetes who have frequent ED visits and determine reasons for revisits. METHODS A single-center analysis was conducted comparing patients referred to the EDRP (n = 420) to historical unexposed controls (n = 791). The primary outcome was the proportion of patients in each frequency group of ED revisits (none, 1 to 3 [infrequent], 4 to 10 [frequent], or >10 [superfrequent]) in the year after the ED index visit. Secondary outcomes were hospitalization rates and International Classification of Diseases-Ninth Revision (ICD-9) diagnoses at ED revisits. RESULTS Superfrequent users, responsible for >20% of total ED visits, made up small but not significantly different proportions of EDRP and control populations, 3.6% and 5.2%, respectively. Superfrequent groups had lower hospital admission rates at ED revisits compared to frequent groups. Mental health disorders (including substance abuse) were the primary, secondary, or tertiary ICD-9 codes in 30.6% (95% confidence interval [CI], 27.7% to 33.5%) and 6.6% (95% CI, 5.1% to 8.2%) in the superfrequent and infrequent groups, respectively. CONCLUSION Direct access to diabetes specialty care from the ED is effective in reducing ED recidivism but not amongst a small subgroup of superfrequent ED users. This group was more likely to have mental health disorders recorded at ED revisits, suggesting that more comprehensive approaches are needed for this population. ABBREVIATIONS EDRP = Emergency Department Diabetes Rapid-referral Program; ED = emergency department; HbA1c = hemoglobin A1c; ICD-9 = International Classification of Diseases-Ninth Revision.
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Palermo NE, Modzelewski KL, Farwell AP, Fosbroke J, Shankar KN, Alexanian SM, Baker WE, Simonson DC, McDonnell ME. OPEN ACCESS TO DIABETES CENTER FROM THE EMERGENCY DEPARTMENT REDUCES HOSPITALIZATIONS IN THE SUSEQUENT YEAR. Endocr Pract 2017; 22:1161-1169. [PMID: 27732094 DOI: 10.4158/e161254.or] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Patients who present to the emergency department (ED) for diabetes without hyperglycemic crisis are at risk of unnecessary hospitalizations and poor outcomes. To address this, the ED Diabetes Rapid-referral Program (EDRP) was designed to provide ED staff with direct booking into the diabetes center. The objective of this study was to determine the effects of the EDRP on hospitalization rate, ED utilization rate, glycemic control, and expenditures. METHODS We conducted a single-center analysis of the EDRP cohort (n = 420) and compared 1-year outcomes to historic controls (n = 791). We also compared EDRP patients who arrived (ARR) to those who did not show (NS). The primary outcome was hospitalization rate over 1 year. Secondary outcomes included ED recidivism rate, hemoglobin A1c (HbA1c), and healthcare expenditures. RESULTS Compared with controls, the EDRP cohort was less likely to be hospitalized (27.1% vs. 41.5%, P<.001) or return to the ED (52.2% vs. 62.3%, P = .001) at the end of 1 year. Total hospitalizations were also lower in the EDRP (157 ± 19 vs. 267 ± 18 per 1,000 persons per year, P<.001). The EDRP cohort had a greater reduction in HbA1c (-2.66 vs. -2.01%, P<.001), which was more pronounced when ARR patients were compared with NS (-2.71% vs. -1.37%, P<.05). The mean per patient institutional healthcare expenditures were lower by $5,461 compared with controls. CONCLUSION Eliminating barriers to scheduling diabetes-focused ambulatory care for ED patients was associated with significant reductions in hospitalization rate, ED recidivism rate, HbA1c, and healthcare expenditures in the subsequent year. ABBREVIATIONS ARR = arrived ED = emergency department EDRP = emergency department diabetes rapid-referral Program HbA1c = hemoglobin A1c NS = no show.
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Abstract
Numerous studies have demonstrated an association between hyperglycemia in the perioperative period and adverse clinical outcomes. Many patients who experience hyperglycemia while hospitalized do not have a known history of diabetes and experience a transient phenomenon often described as "stress hyperglycemia" (SH). We discuss the epidemiology and pathogenesis of SH as well as evidence to date regarding predisposing factors and outcomes. Further research is needed to identify the long-term sequelae of SH as well as perioperative measures that may modulate glucose elevations and optimal treatment strategies.
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Affiliation(s)
- Nadine E Palermo
- Department of Medicine, Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Harvard Medical School, 221 Longwood Ave, Suite 381, Boston, MA, 02115, USA.
| | - Roma Y Gianchandani
- Department of Medicine, Division of Metabolism, Endocrinology and Diabetes, University of Michigan Health Systems, University of Michigan Medical School, 24 Frank Lloyd Wright Drive, Ann Arbor, MI, 48109, USA.
| | - Marie E McDonnell
- Department of Medicine, Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Harvard Medical School, 221 Longwood Ave, Suite 381, Boston, MA, 02115, USA.
| | - Sara M Alexanian
- Department of Medicine, Section of Endocrinology, Diabetes and Nutrition, Boston Medical Center, Boston University School of Medicine, 732 Harrison Ave, 5th Floor, Suite 511, Boston, MA, 02118, USA.
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De Leo S, Palermo NE, Braverman LE. Visual Vignette. Endocr Pract 2016; 22:645. [PMID: 26789345 DOI: 10.4158/ep151138.vv] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Abstract
PURPOSE OF REVIEW Nelson's syndrome is a rare complication that can occur during the course of management of Cushing's disease. This article summarizes the recent literature on the diagnosis, monitoring and treatment of this potentially life-threatening outcome. RECENT FINDINGS Nelson's syndrome, with rising adrenocorticotropin hormone levels and corticotroph tumor progression on diagnostic imaging, can develop following treatment of refractory Cushing's disease with total bilateral adrenalectomy with/without radiotherapy. However, data showing that radiotherapy prevents Nelson's syndrome is inconsistent. In addition to the treatment of Nelson's syndrome with neurosurgery with/without adjuvant radiotherapy, selective somatostatin analogs and dopamine agonists, as well as other novel agents, have been used with increasing frequency in treating cases of Nelson's syndrome with limited benefit. The risk-benefit profile of each of these therapies is still not completely understood. SUMMARY Consensus guidelines on the evaluation and management of Nelson's syndrome are lacking. This article highlights areas in the surveillance of Cushing's disease patients, and diagnostic criteria and treatment regimens for Nelson's syndrome that require further research and review by experts in the field.
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Affiliation(s)
- Nadine E Palermo
- Section of Endocrinology, Diabetes and Nutrition, Boston University School of Medicine, Boston, Massachusetts, USA
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Abstract
Some of the clinically significant causes of vitamin D deficiency in children are secondary to inadequate dietary intake, limited sun exposure, disease states causing malabsorption (celiac disease, gastric and small bowel resection, pancreatic insufficiency from cystic fibrosis) and altered metabolism secondary to medications. In utero and during childhood vitamin D deficiency can have a myriad of health consequences extending beyond musculoskeletal health to acute and chronic disease. In this review, it discusses the prevalence of vitamin D deficiency, clinical spectrum of disease presentations in children with emphasis in children with disabilities, vitamin D's role in bone and nonskeletal heath as well as recommendations for prevention and treatment of vitamin D deficiency.
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Affiliation(s)
- Nadine E Palermo
- Department of Medicine, Section of Endocrinology, Diabetes, and Nutrition Vitamin D, Skin and Bone Research Laboratory, Boston University Medical Center, Boston, MA, USA
| | - Michael F Holick
- Department of Medicine, Section of Endocrinology, Diabetes, and Nutrition Vitamin D, Skin and Bone Research Laboratory, Boston University Medical Center, Boston, MA, USA
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