Impact of Charlson Comorbidity Index on in-hospital mortality of patients with hyperglycemic crises: A propensity score matching analysis.

AIM: This study was designed to investigate the association between Charlson Comorbidity Index (CCI) and in-hospital mortality and other clinical outcomes among patients with hyperglycemic crises. METHOD: This retrospective cohort study was conducted using data from electric medical records. A total of 1668 diabetic patients with hyperglycemic crises from six tertiary hospitals met the inclusion criteria. CCI < 4 was defined as low CCI and CCI ≥ 4 was defined as high CCI. Propensity score matching (PSM) with the 1:1 nearest neighbour matching method and the caliper value of 0.02 was used to match the baseline characteristics of patients with high CCI and low CCI to reduce the confounding bias. In-hospital mortality, ICU admission, hypoglycemia, hypokalemia, acute kidney injury, length of stay (LOS), and hospitalisation expense between low CCI and high CCI were compared and assessed. Univariate and multivariate regression were applied to estimate the impact of CCI on in-hospital and other clinical outcomes. OUTCOME: One hundred twenty-one hyperglycemic crisis (HC) patients died with a mortality rate of 7.3%. After PSM, compared with low CCI, patients with high CCI suffered higher in-hospital mortality, ICU admission, LOS, and hospitalisation expenses. After multivariate regression, age (aOR: 1.12, 95% confidence interval [CI]: 1.06-1.18, p < 0.001), CCI(aOR: 4.42, 95% CI: 1.56-12.53, p = 0.005), uninsured (aOR: 22.32, 95% CI: 4.26-116.94, p < 0.001), shock (aOR: 10.57, 95% CI: 1.41-79.09, p = 0.022), mechanical ventilation (aOR: 75.29, 95% CI: 12.37-458.28, p < 0.001), and hypertension (aOR: 4.34, 95% CI: 1.37-13.82, p = 0.013) were independent risk factors of in-hospital mortality of HC patients. Besides, high CCI was an independent risk factor for higher ICU Admission (aOR: 5.91, 95% CI: 2.31-15.08, p < 0.001), hypoglycemia (aOR: 2.19, 95% CI:1.01-4.08, p = 0.049), longer LOS (aOR: 1.23, 95% CI: 1.19-2.27, p = 0.021), and higher hospitalisation expense (aOR: 2089.97, 95% CI: 193.33-3988.61, p = 0.031) of HC patients. CONCLUSION: CCI is associated with in-hospital mortality, ICU admission, hypoglycemia, LOS, and hospitalisation expense of HC patients. CCI could be an ideal indicator to identify, monitor, and manage chronic comorbidities among HC patients.

High versus low chloride load in adult hyperglycemic emergencies with acute kidney injury: a multicenter retrospective cohort study.

Hyperglycemic emergencies frequently lead to acute kidney injury (AKI) and require treatment with large amount of intravenous fluids. However, the effects of chloride loading on this population have not yet been investigated. We conducted a multicenter, retrospective, cohort study in 21 acute-care hospitals in Japan. The study included hospitalized adult patients with diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic syndrome (HHS) who had AKI upon arrival. The patients were classified into high and low chloride groups based on the amount of chloride administered within the first 48 h of their arrival. The primary outcome was recovery from AKI; secondary outcome was major adverse kidney events within 30 days (MAKE30), including mortality and prolonged renal failure. A total of 390 patients with AKI, including 268 (69%) with DKA and 122 (31%) with HHS, were included in the study. Using the criteria of Kidney Disease Improving Global Outcomes, the severity of AKI in the patients was Stage 1 (n = 159, 41%), Stage 2 (n = 121, 31%), and Stage 3 (n = 110, 28%). The analysis showed no significant difference between the two groups in recovery from AKI (adjusted hazard ratio, 0.96; 95% CI 0.72-1.28; P = 0.78) and in MAKE30 (adjusted odds ratio, 0.91; 95% CI 0.45-1.76; P = 0.80). Chloride loading with fluid administration had no significant impact on recovery from AKI in patients with hyperglycemic emergencies.Trial Registration This study was registered in the UMIN clinical trial registration system (UMIN000025393, registered December 23, 2016).

Causas precipitantes de crisis hiperglicémicas agudas en pacientes internados en el Centro Médico Nacional - Hospital Nacional / Precipiting causes of acute hyperglycemic crisis in patients in the Centro Médico Nacional - Hospital Nacional

Introducción: las crisis hiperglicémicas agudas son las emergencias endocrinológicas más frecuentes en la práctica clínica y junto a la hipoglucemia se las describe como las complicaciones metabólicas agudas graves del paciente diabético. Objetivo: identificar las causas precipitantes de crisis hiperglicémicas agudas en pacientes internados en el Centro Médico - Hospital Nacional. Metodología: estudio observacional, descriptivo, de corte transversal de pacientes internados en el Centro Médico Hospital Nacional, durante el periodo de mayo 2021 a octubre del 2023. Los datos fueron obtenidos con la revisión de las fichas clínicas. Resultados: de los 100 pacientes evaluados, la crisis hiperglicémica aguda más frecuente fue la Cetoacidosis diabética (CAD) 53 %, seguida del Estado hiperosmolar hiperglicémico (EHH) 25 % y el estado mixto 22 %. Los desencadenantes más frecuentes fueron el abandono del tratamiento, debut de la enfermedad e infecciones. La mortalidad global fue del 12 %. Conclusión: la causa más frecuente de descompensación fueron el abandono del tratamiento, la diabetes de novo y procesos infecciosos.

Introduction: hyperglycemic crises are the most frequent endocrinological emergencies in clinical practice and, along with hypoglycemia, are described as serious acute metabolic complications in diabetic patients. Objective: to identify the precipiting causes of acute hyperglycemic crisis in hospitalized patients in the Centro Médico Nacional - Hospital National. Methodology: this was an observational, descriptive, cross -sectional study of patients hospitalized at the Centro Médico Nacional - Hospital National, from May 2021 to October 2023. The data were obtained from a review of the clinical records. Results: Of the 100 patients evaluated, the most frequent acute hyperglycemic crisis was diabetic ketoacidosis (CAD) 53 %, followed by the hyperglycemic hyperosmolar state (EHH) 25 % and the mixed state 22 %. The most frequent triggers were the abandonment of treatment, disease debut and infections. Global mortality was 12 %. Conclusion: the most frequent causes of decompensations were abandoning treatment, novo diabetes and infectious processes.

Clinical profile of patients with diabetic ketoacidosis and hyperglycemic hyperosmolar syndrome in Japan: a multicenter retrospective cohort study.

INTRODUCTION: Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar syndrome (HHS) are life-threatening complications of diabetes mellitus. Their clinical profiles have not been fully investigated. METHODS: A multicenter retrospective cohort study was conducted in 21 acute care hospitals in Japan. Patients included were adults aged 18 or older who had been hospitalized from January 1, 2012, to December 31, 2016 due to DKA or HHS. The data were extracted from patient medical records. A four-group comparison (mild DKA, moderate DKA, severe DKA, and HHS) was performed to evaluate outcomes. RESULTS: A total of 771 patients including 545 patients with DKA and 226 patients with HHS were identified during the study period. The major precipitating factors of disease episodes were poor medication compliance, infectious diseases, and excessive drinking of sugar-sweetened beverages. The median hospital stay was 16 days [IQR 10-26 days]. The intensive care unit (ICU) admission rate was 44.4% (mean) and the rate at each hospital ranged from 0 to 100%. The in-hospital mortality rate was 2.8% in patients with DKA and 7.1% in the HHS group. No significant difference in mortality was seen among the three DKA groups. CONCLUSIONS: The mortality rate of patients with DKA in Japan is similar to other studies, while that of HHS was lower. The ICU admission rate varied among institutions. There was no significant association between the severity of DKA and mortality in the study population. TRIAL REGISTRATION: This study is registered in the UMIN clinical Trial Registration System (UMIN000025393, Registered 23th December 2016).

Predicting readmission due to severe hyperglycemia after a hyperglycemic crisis episode.

AIM: This study aimed to investigate the readmission pattern and risk factors for patients who experienced a hyperglycemic crisis. METHODS: Patients admitted to MacKay Memorial Hospital for diabetic ketoacidosis (DKA) or hyperglycemic hyperosmolar state (HHS) between January 2016 and April 2019 were studied. The timing of the first readmission for hyperglycemia and other causes was recorded. Kaplan-Meier analysis was used to compare patients with hyperglycemia and all-cause readmissions. Cox regression was used to identify independent predictors for hyperglycemia and all-cause readmission post-discharge. RESULTS: The study cohort included 410 patients, and 15.3 % and 46.3 % of them had hyperglycemia and all-cause readmissions, respectively. The DKA and HHS group showed a similar incidence for hyperglycemia, with the latter group showing a higher incidence of all-cause readmissions. The significant predictors of hyperglycemia readmissions included young age, smoking, hypoglycemia, higher effective osmolality, and hyperthyroidism in the DKA group and higher glycated hemoglobin level in the HHS group. CONCLUSIONS: Patients who experienced DKA and HHS had similar hyperglycemia readmission rates; however, predictors in the DKA group were not applicable to the HHS group. Designing different strategies for different types of hyperglycemic crisis is necessary for preventing readmission.

Lifetime risk and health-care burden of diabetic ketoacidosis: A population-based study.

Objective: Diabetic ketoacidosis (DKA) is a life-threatening complication of both type 1 and type 2 diabetes. We aimed to assess population-based rates, trends and outcomes of patients with DKA. Design and methods: This is a nationwide cohort study using hospital discharge claims data from 2010 to 2018 in Switzerland. Incidence rates and in-hospital outcomes of DKA were analyzed throughout lifetime for children (0-9 years), adolescents (10-19 years), and adults (20-29, 30-59, and 60-90 years). Analyses were stratified for type of diabetes mellitus and sex. Results: In total, 5,544 hospitalizations with DKA were identified, of whom 3,847 were seen in patients with type 1 diabetes and 1,697 in type 2 diabetes. Incidence rates of DKA among patients with type 1 diabetes were highest during adolescence with 17.67 (girls) and 13.87 (boys) events per 100,000 person-years (incidence rate difference [IRD]: -3.80 [95% CI, -5.59 to -2.02]) and decreased with age in both sexes thereafter. Incidence rates of DKA in patients with type 2 diabetes were low up to an age of 40 years and rose to 5.26 (females) and 6.82 (males) per 100,000 person-years in adults aged 60-90 years. Diabetic ketoacidosis was associated with relevant health-care burden independent of age, sex, or type of diabetes. The population-based incidence rate of DKA increased over time from 7.22 per 100,000 person-years in 2010 to 9.49 per 100,000 person-years in 2018. Conclusions: In type 1 diabetes highest incidence rates of DKA hospitalizations were observed among adolescent females. In comparison, in patients with type 2 diabetes the risk for DKA steadily increased with age with higher rates in adult males. Over the 9 year study period, incidence rates of DKA were increasing irrespective of type of diabetes. DKA was associated with a high burden of disease reflected by high rates of intensive care unit admission, prolonged hospital stay and high mortality rates, especially in elderly.

Impact of acute hyperglycemic crisis episode on survival in individuals with diabetic foot ulcer using a machine learning approach.

Objective: The outcome of DFUs concomitant with HCE remains unknown. This study aimed to investigate mortality rates and identify risk factors of mortality in patients with DFUs-HCE. Methods: 27 inpatients with DFUs-HCE were retrospectively enrolled in a cohort design, they were compared to 93 inpatients with DFUs in a city designated emergency center, between January 2016 and January 2021. After a 6-year followed-up, clinical characteristic, amputation and survival rates were compared. Extreme gradient boosting was further used to explore the relative importance of HCE and other risk factors to all-cause mortality in DFUs. Results: Patients with DFUs-HCE were more likely to havedementia, acute kidney injury and septic shock, whereas DFUs were more likely to have diabetic peripheral neuropathy and ulcer recurrence (P<0.05). No significant difference was observed on the amputation rate and diabetes duration. Both Kaplan-Meier curves and adjusted Cox proportional model revealed that DFUs-HCE was associated with a higher mortality compared with DFUs (P<0.05). HCE significantly increased the risk of mortality in patients with DFUs (hazard ratio, 1.941; 95% CI 1.018-3.700; P = 0.044) and was independent from other confounding factors (age, sex, diabetes duration, Wagner grades and Charlson Comorbidity Index). The XGBoost model also revealed that HCE was one of the most important risk factors associated with all-cause mortality in patients with DFUs. Conclusions: DFUs-HCE had significantly lower immediate survival rates (first 1-6 month) than DFUs alone. HCE is an important risk factor for death in DFUs patients.

Clinical profile of adult patients with Hyperglycemic Crisis at the De La Salle University Medical Center, a ten-year retrospective study

Abstract@#This current study aims to report the clinical profiles and characteristics of diabetic patients who had been admitted for hyperglycemic crises from 2007 to 2017 at our institution. @*Methodology@#We conducted a retrospective study in a tertiary care university hospital outside Metro Manila. The data gathered were divided into three categories: clinical data, biochemical data and precipitating factors. @*Results@#A total of 3,120 adult patients with diabetes mellitus were admitted for various reasons, and 71 cases presented with DKA or HHS over the 10-year period of review which is equivalent to 2% of all diabetes mellitus cases admitted. Forty-six (64.79%) of the patients with hyperglycemic crises were known diabetics with a duration of 7-13 years. Majority of patients were not taking anti diabetic medications upon admission. Most patients with hyperglycemic crises were tachycardic and hypertensive upon admission. Majority were discharged and improved. Majority of the cases 53 (81.69%) had DKA. The most common precipitating factor in DKA and HHS was infection.@*Conclusion@#In conclusion, the biochemical profiles in our series did not significantly differ from the past study by Gatbonton et.al (1998). Despite the advent of new therapies for diabetes mellitus control, mortality among the patients with hyperglycemic crises was slightly higher in our study at 11% compared to the global reported data of 2-10%. One of the reasons could be the minimal improvements in our health care delivery system that is still unable to cater to the needs of diabetic Filipinos. Early screening programs should be done for patients beginning age 40 years and even earlier for those with risk factors for prompt detection and treatment of diabetes mellitus. Education and awareness should be strengthened for patients with diabetes mellitus to avoid the crises by emphasizing the importance of regular follow-up, monitoring and compliance with a diabetic regimen, especially with insulin and multiple OADs (oral anti- diabetic drugs) since the disease is progressive, and timely intensification of therapy is needed.

Analysis of demographic and clinical characteristics of 1668 patients with different types of hyperglycemic crisis / 中华内分泌外科杂志

Objective:To analyze and compare the demographic and clinical characteristics of patients with different types of hyperglycemic crisis, so as to provide clinical basis for the prevention and treatment of hyperglycemic crisis.Methods:The data of patients with hyperglycemic crisis in six First-level general hospitals in Chongqing from Jan. 2015 to Dec. 2020 were retrospectively collected and divided into diabetic ketoacidosis (DKA) , hyperglycemic hyperosmolar state (HHS) and diabetic ketoacidosis with hyperglycemic hyperosmotic state (DKA-HHS) . The demographic and clinical characteristics of each group were analyzed by descriptive method.Results:A total of 1668 patients were collected, among whom1388 were DKA, 113 were HHS and 167 were DKA-HHS. The proportion of T2DM in DKA was 90.1%, the proportion of urban residents’ medical insurance, farmers and retirees was higher in the three groups, and the incidence of hyperglycemic crisis in patients above 60 years old was the highest in all age groups. The incidence of DKA and HHS changed little during the six years, but increased significantly in the DKA-HHS group. Shock, disturbance of consciousness, hospitalization expenses and mortality in the DKA-HHS group were higher than those in the other two groups.Conclusions:There are differences in demographic and clinical characteristics among different types of hyperglycemic crisis. Clinically, more attention should be paid to patients above 60 years old and patients with hyperglycemic crisis such as DKA-HHS. Health education and guidance for diabetic patients in high-risk groups should be strengthened in order to reduce the occurrence of diabetic hyperglycemic crisis.

A quality improvement initiative to successfully reduce the frequency of hypoglycemia during treatment of hyperglycemic crises at an academic safety-net hospital: Insights and results.

BACKGROUND: Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) are potentially life-threatening complications of diabetes. Many hospitals have developed protocols to guide the management of these conditions and align with best practices. One of the main complications encountered in the treatment of hyperglycemic crises is hypoglycemia. METHODS: At our institution, we undertook a review of our insulin infusion titration protocol, rates of hypoglycemia, and time to clinical resolution for patients with hyperglycemic crises. A multidisciplinary team performed a literature review and analyzed baseline hospital data with the existing protocol. With the input of multiple stakeholders, several changes were made to the titration algorithm over multiple PDSA cycles to refine the protocol. Effectiveness and safety of the protocol, as well as fidelity with the protocol, were assessed after each PDSA cycle. RESULTS: After the initial cycle, chart review showed a reduction in hypoglycemia rates of more than 50% in patients treated with the new protocol without any increase in time to resolution of DKA. A second version of the protocol was implemented to improve usability, and improvement in hypoglycemia was maintained. CONCLUSION: Despite the fact that the initial protocol had been developed based on best practice recommendations, rates of hypoglycemia were initially high. Critical assessment of pitfalls in management allowed changes to the protocol that significantly and sustainably reduced hypoglycemia.

COVID-19 and Combined Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar Nonketotic Coma: Report of 11 Cases.

We report 11 cases of combined diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar nonketotic coma (HHNK) in coronavirus 2019 patients who presented to our institution in New Jersey, USA. The median age was 47 years (range 12-88 years). Out of the 11 patients, 7 were male and 4 were female. Out of 11 patients, 8 had type 2 diabetes mellitus (DM), 2 had undiagnosed DM, and 1 had type 1 DM. Presenting complaints included altered mental status, weakness, shortness of breath, cough, fever, vomiting, abdominal pain, chest pain, and foot pain. Out of 11 patients, pneumonia was diagnosed at presentation in 8 patients, while in 3 patients, chest X-ray was clear. Median value of initial glucose on presentation was 974 mg/dL (range 549-1556 mg/dL), and hemoglobin A1c on presentation was 13.8%. The median value of anion gap was 34 mEq/L. Out of the 11 patients, ketonemia was moderate in 6 patients, large in 3, and small in 2 patients. Acute kidney injury (AKI) occurred in 9 patients and 2 patients required renal replacement therapy. Out of the 11 patients, 6 required mechanical ventilation and 7 patients died. All the 6 patients requiring mechanical ventilation died. Our case series shows COVID-19 infection can precipitate acute metabolic complications in known DM patients or as first manifestation in undiagnosed DM patients. Patients can present with DKA/HHNK symptoms and/or respiratory symptoms. Mechanical ventilation is a poor prognostic factor. Further studies are needed to characterize prognostic factors associated with mortality in this vulnerable patient population.

COVID-19 and Diabetic Ketoacidosis: A Single Center Experience.

BACKGROUND AND OBJECTIVES:  To describe the clinical characteristics and outcomes of hospitalized coronavirus disease 2019 (COVID-19) patients with diabetic ketoacidosis (DKA) -- a single center tertiary hospital experience. MATERIALS AND METHODS:  A retrospective study was conducted among patients admitted to our hospital in the United States between March 1st and June 15th, 2020 with DKA and severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) infection known as COVID-19. We compared the baseline characteristics, laboratory data, and clinical course between survivors and nonsurvivors to identify the risk factors associated with mortality in the patients with DKA. RESULTS:  A total number of 43 patients were included in this study. The median age was 52 years. Thirty-three (76.7%) patients were male. Median value of initial glucose on presentation was 553 mg/dL (300.0-1927.0 mg/dL). On admission, 33 (76.7%) patients had glycated hemoglobin (HbA1c) ≥ 8% (64 mmol/mol) and HbA1c was not obtained in 10 (23.3%) patients. Acute kidney injury (AKI) was seen in 37 (86.0%) patients, 6 (14%) patients required renal replacement therapy and 22 (51.2%) required mechanical ventilation. Among the 43 patients, 25 (58.1%) died. Out of 25 patients who died 15 (60.0%) were Hispanics, 6 (24.0%) were White, 3 (12.0%) were African American, 1 (4%) was Arabic, and 1 (4%) was Asian. The patients who died were older in age than who survived (mean age 58 ± 6.13 vs 46 ± 9.39; p = 0.023). Some 95% of the patients requiring mechanical ventilation died (odds ratio [OR]: 89.25; 95% confidence interval [CI]: 9.10-874.96); p = 0.001). Compared to survivors, nonsurvivors had significantly higher d-dimer (13.00 ± 3.20 mcg/mL vs 6.15 ± 3.66 mcg/mL; p< 0.006) and peak ferritin values (2763.66 ± 1105.32 ng/mL vs 835.16 ± 257.07 ng/mL; p= 0.016).  Conclusion: Our retrospective study shows COVID-19 infection may present as DKA in patients with diabetes mellitus (DM). Older age, mechanical ventilation, elevated d-dimer, and ferritin are associated with poor prognosis in these patients. Our study shows that COVID-19 is associated with substantial mortality in DKA patients and adds to the limited literature available regarding poor risk factors associated with mortality in these patients.

Hyperglycemic Crisis Characteristics and Outcome of Care in Adult Patients without and with a History of Diabetes in Tigrai, Ethiopia: Comparative Study.

OBJECTIVE: To compare hyperglycemic crisis characteristics and outcomes of care in adult patients without and with a history of diabetes in Tigrai, Ethiopia. METHODS: A retrospective record review of diabetes patients, 196 without and 393 with a history of diabetes who had been treated in the medical wards from September 1/2017 to August 31/2018, aged 18 years and above was included. An independent-samples t-test/Mann-Whitney tests, χ2-test, and logistic regression analysis were used to analyze the data using SPSS version 25.0. RESULTS: Patients without history of diabetes were younger [43.9±12.6 vs 48.4±14.9], more rural residents [53.1% vs 30.3%], lower proportion of type 2 diabetes [38.3% vs 53.7%], hyperosmolar hyperglycemic state [15.8% vs 31.8%], with lower mortality rate [8.7% vs 15.5%] compared to with a history of diabetes. A higher mortality reported in rural residents [13.5% vs 3.3%; without vs 21.8% vs 12.8%; with history], and lower urine ketones [1.9± 1.3 vs 2.8± 1.1; without vs 1.6± 1.2 vs 2.2± 1.0; with a history] compared to their counterparts in both patients, respectively. Rural residents [AOR (95% CI); 3.1 (1.8, 5.4)]; medical history of stroke [AOR (95% CI); 2.7 (1.3, 5.6)]; type 2 diabetes [AOR (95% CI); 2.3 (1.1, 4.7)], hyperglycemic hyperosmolar state [AOR (95% CI); 2.4 (1.1, 5.4)]; and with a history of diabetes [AOR (95% CI); 2.0 (1.04, 3.8)] were significantly associated with mortality, but polydipsia [AOR (95% CI); 0.47 (0.27, 0.81)] was preventive. CONCLUSION: This finding suggests that rural residents, medical history of stroke, type 2 diabetes, hyperglycemic hyperosmolar state, and with a history of diabetes were independent predictors of mortality while polydipsia was preventive. Therefore, the need for more public health awareness campaigns, screening for people having known risk factors, and expansion of diabetes care services to the primary health care units is a fundamental measure.

Potassium Concentration in Initial Fluid Therapy and In-Hospital Mortality of Patients with Diabetic Ketoacidosis.

CONTEXT: Guidelines worldwide recommend potassium replacement of 10 to 40 mmol/L in the initial fluid therapy for patients with diabetic ketoacidosis. However, evidence is lacking as to the association between infused potassium concentration and mortality. OBJECTIVE: We aimed to determine the association between infused potassium concentration and in-hospital mortality. METHODS: Using the Japanese Diagnosis Procedure Combination database, we retrospectively identified inpatients admitted for treatment of diabetic ketoacidosis from July 2010 to March 2018. Patients with kidney dysfunction or serum potassium abnormalities were excluded. We evaluated the association of the potassium concentration in the total infused solutions in the first 2 days of hospitalization with 28-day in-hospital mortality using multivariable regression analysis with a cubic spline model. We also assessed the association between potassium concentration and occurrence of hyperkalemia. RESULTS: We identified 14 216 patients with diabetic ketoacidosis and observed 261 deaths. The quartile cut-points for potassium concentration were 7.7, 11.4, and 16.1 mmol/L. Within the range of approximately 10 to 40 mmol/L, potassium concentration was not associated with occurrence of hyperkalemia or death. Lower potassium concentrations were associated with higher 28-day in-hospital mortality; the odds ratio for patients receiving 8 mmol/L was 1.69 (95% CI, 1.03 to 2.78; reference: 20 mmol/L), and the odds ratio increased monotonically as potassium concentration decreased further. CONCLUSION: Patients receiving potassium replacement at concentrations of 10 to 40 mmol/L had similar in-hospital mortality rates, whereas lower concentrations were associated with higher mortality.

Risk of Dementia in Diabetic Patients with Hyperglycemic Crisis: A Nationwide Taiwanese Population-Based Cohort Study.

BACKGROUND: A hyperglycemic crisis episode (HCE) signifies poor control of diabetes and may increase the risk of dementia via microvascular and macrovascular injuries. OBJECTIVES: We conducted this study to clarify this issue, which remains unclear. METHODS: Using the Taiwan National Health Insurance Database, we identified 9,466 diabetic patients with HCE and the identical number of diabetic patients without HCE who were matched by age and sex for this nationwide population-based cohort study. The risk of dementia was compared between the 2 cohorts by following up until 2014. Investigation of independent predictors of dementia was also done. RESULTS: In the overall analysis, the risk of dementia between the 2 cohorts was not different. However, stratified analyses showed that patients with HCE had a higher risk of subsequent dementia in the age subgroup of 45-54 and 55-64 years (adjusted odds ratio [AOR]: 2.4, 95% confidence interval [CI]: 1.6-3.6, and AOR: 1.2, 95% CI: 1.0-1.5, respectively). In the overall analysis, older age, female sex, ≥3 HCEs, hypertension, hyperlipidemia, depression, cerebrovascular disease, Parkinson's disease, and head injury were independent predictors. CONCLUSIONS: HCE increased the risk of dementia in diabetic patients aged 45-64 years. Dementia was predicted by ≥3 HCEs. Prevention of recurrent HCE, control of comorbidities, and close follow-up of cognitive decline and dementia are suggested in patients with HCE.

Is subcutaneous insulin administration adequate for the management of hyperglycemic crisis in COVID-19?

There is a desperate need to explore different insulin administration strategies, particularly in coronavirus disease 2019 (COVID-19) patients with hyperglycemic crisis. Noteworthily, diabetes mellitus (DM) and poorly controlled blood glucose increase the risk of mortality and severity of COVID-19. Intravenous (IV) insulin administration with hourly monitoring of blood glucose is the ideal approach in managing patients with hyperglycemic crisis, but it is not judicious to be applied in developing countries where shortage of personal protective equipment (PPE) is a major issue. Furthermore, increasing the probability of "already greater risks" for doctors or other healthcare workers contracting COVID-19 seems inappropriate. Thus, an alternative administration strategy and more moderate glucose monitoring to reduce the contact exposure of healthcare workers with COVID-19 patients, by ensuring appropriate blood glucose levels, needs to be performed in this critical pandemic era. Subcutaneous (SC) rapid-acting insulin analog administration could presumably be a solution to this contentious issue.

Management of extracellular volume in patients with end-stage kidney disease and severe hyperglycemia.

This commentary addresses volume replacement in hyperglycemic crises in patients with end-stage kidney disease (ESKD). The management of volume issues in this group of patients should not be based on guidelines for management of hyperglycemic crises, but should be individualized and based on directed patient medical history, physical examination, and imaging of the heart and lungs. A scheme for combining information from these three sources is provided.

Intravenous insulin therapy in diabetes mellitus with hyperglycemic crisis and intercurrent illness.

Background Hyperglycemic crisis is one of the complications of diabetes mellitus, which is common in hospitalized diabetic patient with intercurrent illness, requiring immediate action to control blood glucose. As an effort to attain rapid, gradually and more definite blood glucose, insulin is given intravenously. This study aimed to explore the patterns of blood glucose in hyperglycemic crisis and intercurrent illness, precipitating conditions, insulin regimen and blood glucose (BG) level results. Methods It was a cross-sectional study conducted on type 2 diabetic patients. The inclusion criteria were as follows: hospitalized in the general/internal medicine ward with or without any complication or comorbidity receiving intravenous insulin therapy; have pre- and post-BG data after insulin intervention. Results In 3 months of the study period, 22 patients fulfilled the inclusion criteria with 28 cases of intravenous insulin therapy, and 1 patient could get more than one intervention. The major condition toward a hyperglycemic crisis condition was infection. The patient's BG before interventions was 243 mg/dL to more than 600 mg/dL. The dosage of insulin varied from 4 to 10 units per hour, intravenously with a frequency of 1-4 times. The dosage consideration was not only based on BG levels but also on the patient's condition. The reduction in BG level varied greatly between 0.2 and 28.1 mg/dL per unit of insulin. The BG level of three patients did not decrease. On the other hand, one patient experienced mild hypoglycemia. Conclusions Infection conditions were the most common factor for the hyperglycemia crisis. Moreover, intravenous insulin dosing was done individually, and there was a large variation in the results of the decrease in BG levels.

Risk of hyperglycemic crisis episode in diabetic patients with depression: A nationwide population-based cohort study.

AIMS: This study aims to investigate the risk of hyperglycemic crisis episode (HCE) in diabetic patients with depression and to examine the relationship between the duration of antidepressants use and the risk of HCE. METHODS: In all, 26,746 diabetic patients with depression and 106,853 controls (without depression) matched by gender, age, index year, and Charlson Comorbidity Index (CCI) score were included between 1999 and 2010, then followed until the end of 2013. During the follow-up period, participants who developed HCE were identified. Cox regression analysis was used to calculate the hazard ratio (HR) with 95% confidence interval (CI) of the HCE incidence rate between the two groups studied. RESULTS: Diabetic patients with depression had a significantly increased risk of HCE compared to unaffected controls after adjusted for gender, age, CCI score, and duration of antidepressants use (2.87 versus 2.50 per 1000 person-years, HR: 1.78, 95% CI: 1.56-2.03). Also, long-term use of antidepressants in diabetic patients with depression showed a significantly reduced risk of HCE compared to non-users after adjusting for the above-mentioned variables (HR: 0.44, 95% CI: 0.35-0.55). CONCLUSIONS: This study shows diabetic patients with depression have an increased risk of HCE, and the use of antidepressants may reduce its risk.