Treatment of Diabetic Ketoacidosis (DKA)/Hyperglycemic Hyperosmolar State (HHS): Novel Advances in the Management of Hyperglycemic Crises (UK Versus USA)

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. Summary: 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

The Management of Hospital In-patients with Diabetes Mellitus

In the UK, the prevalence of diabetes in adults in the general population is currently reported as just over 6% in 2014-15 [1]. This rose from a prevalence of 5.5% in 2010. However, the most recent data from the 2016 United Kingdom National Diabetes In-patient Audit reported that the prevalence of diabetes amongst hospitalised in-patients was 17% [2]. This represented a rise of over 15% since the first National Diabetes In-patient Audit was carried out in 2010, and was the same rise in prevalence seen in the general population during that time. Thus diabetes is disproportionately over represented in the in-patient population. It has been recognised for many years that in-patients with diabetes experience ‘glucose-related’ harms. Any form of dysglycaemia is associated with increased harms – in terms of poor outcomes (however that is defined) and also increased mortality [3]. For many years it was well recognised that having long term high glucose concentrations was associated with an increased risk of developing the long term micro and macrovascular complications of diabetes. It was only with the publication of the two seminal trials, the Diabetes Control and Complications Trial in type 1 diabetes and the United Kingdom Prospective Diabetes Study in type 2 diabetes that showed conclusively that in an outpatient population tight glycaemic control was associated with a reduced risk of developing those complications [4,5]. However, to date whilst there are a great deal of data to show that high glucose concentrations are associated with harm in hospitalised in-patients with diabetes, there are almost no data to show that improving glucose concentrations is associated with benefit. However, most authorities agree that glucose concentrations between 6.0 and 10.0mmol/l (with an acceptable range of 4.0 to 12.0mmol/l) are likely to be most beneficial (or rather, least likely to be associated with harm). In the UK there is an organisation called the Joint British Diabetes Societies for Inpatient Care group (JBDS), of which I am a senior member. JBDS is a group of professionals interested in the care of in-patients with diabetes. This group, which is funded by Diabetes UK and the Association of British Clinical Diabetologists and is a collaboration between these two national organisations and the National Diabetes Inpatient Specialist Nurse Group, had as it’s ‘mission statement’ the focus on producing evidence based or, where this was not possible, consensus based, clinical guidelines for the management of diabetes in hospitalised in-patients. These guidelines were designed to be used by non-specialists, and written in a user friendly way to make them clinically useful. I have been involved in writing or contributing to most of the guidelines produced by the group, and have been the lead author on two of the most widely read / used documents – peri-operative care and diabetic ketoacidosis. Indeed, as a result of my involvement in these writing groups, I am now recognised as an international expert on these two subjects. I am regularly invited to speak on these subjects, but also invited to write about them as well. This thesis is a journey through various aspects of my involvement in in-patient care for patients with diabetes from the time I was first appointed as a consultant in Norwich in 2004 to the spring of 2017. In particular my hypothesis is that because of the work I and others have published, the management of in-patients with diabetes has improved the care of this vulnerable group

Defining and characterising diabetic ketoacidosis in adults

Aims: Diabetic ketoacidosis (DKA) remains one of the most frequently encountered diabetes related emergencies, and despite updates in management and increasing standardisation of care, still has an appreciable morbidity and mortality. This review focusses on the pathophysiology and epidemiology of DKA, but also on the importance of having a standardised definition. Methods: Relevant data were reviewed where there was available basic science or clinical papers published in peer-reviewed international journals on DKA. These included consensus documents and national or international guidelines Results: The prevalence of DKA varies around the world, but part of this could be down to the way the condition is defined. Examples of this difference include the recent studies on sodium glucose co-transporter inhibitors in people with type 1 and type 2 diabetes which have all been associated with increased rates of DKA, but have highlighted how differences in definitions can make comparisons between agents very difficult. Conclusions: DKA should only be diagnosed when all three components are present – the ‘D’, the ‘K’ and the ‘A’. In addition, the definitions used to diagnose DKA should be standardised – in particular for clinical trials

The endocrine management of intractable masturbation after epilepsy surgery: A case report and literature review

Intractable masturbation has been reported after epilepsy surgery and can be difficult to control, we present a case treated with cyproterone acetate and haloperidol to achieve an endocrine based resolution of symptoms

Gaps in our knowledge of managing inpatient dysglycaemia and diabetes in non‐critically ill adults: A call for further research

Aims: To describe the gaps in knowledge for the care of people in the hospital who have dysglycaemia or diabetes. Methods: A review of the current literature and the authors' knowledge of the subject. Results: Recent data has suggested that the prevalence of hospitalised people with diabetes is approximately three times the prevalence in the general population and is growing annually. A wealth of observational data over the last 4 decades has shown that people with hyperglycaemia, severe hypoglycaemia or diabetes, all experience more harm whilst in the hospital than those who do not have the condition. This often equates to a longer length of stay and thus higher costs. To date, the proportion of federal funding aimed at addressing the harms that people with dysglycaemia experience in hospitals has been very small compared to outpatient studies. National organisations, such as the Joint British Diabetes Societies for Inpatient Care, the American Diabetes Association and the Endocrine Society have produced guidelines or consensus statements on the management of various aspects of inpatient care. However, whilst a lot of these have been based on evidence, much remains based on expert opinion and thus low-quality evidence. Conclusions: This review highlights that inpatient diabetes is an underfunded and under-researched area

Predictors of outcomes in diabetic foot osteomyelitis treated initially with conservative (nonsurgical) medical management: A retrospective study

The optimal way to manage diabetic foot osteomyelitis remains uncertain, with debate in the literature as to whether it should be managed conservatively (ie, nonsurgically) or surgically. We aimed to identify clinical variables that influence outcomes of nonsurgical management in diabetic foot osteomyelitis. We conducted a retrospective study of consecutive patients with diabetes presenting to a tertiary center between 2007 and 2011 with foot osteomyelitis initially treated with nonsurgical management. Remission was defined as wound healing with no clinical or radiological signs of osteomyelitis at the initial or contiguous sites 12 months after clinical and/or radiological resolution. Nine demographic and clinical variables including osteomyelitis site and presence of foot pulses were analyzed. We identified 100 cases, of which 85 fulfilled the criteria for analysis. After a 12-month follow-up period, 54 (63.5%) had achieved remission with nonsurgical management alone with a median (interquartile range) duration of antibiotic treatment of 10.8 (10.1) weeks. Of these, 14 (26%) were admitted for intravenous antibiotics. The absence of pedal pulses in the affected foot (n = 34) was associated with a significantly longer duration of antibiotic therapy to achieve remission, 8.7 (7.1) versus 15.9 (13.3) weeks (P = .003). Osteomyelitis affecting the metatarsal was more likely to be amputated than other sites of the foot (P = .016). In line with previous data, we have shown that almost two thirds of patients presenting with osteomyelitis healed without undergoing surgical bone resection

Pale retinal vessels in newly diagnosed type 2 diabetes

A previously well 52‐year‐old man was seen with a 3‐week history of hyperglycaemic symptoms. He had a BMI of 40.8 kg/m2, with no evidence of eruptive xanthomas. His random blood glucose was 19.0 mmol/l (reference range 3.5–6.9 mmol/l), with an HbA1c concentration of 128 (28–42) mmol/mol [13.9 (4.7–6.0)%]. A venous blood sample was reported as being ‘turbid’, with a serum triglyceride level of 128.4 (0.5–1.7) mmol/l. His visual acuity was normal

The effects of hypoglycemia and dementia on cardiovascular events, falls and fractures and all-cause mortality in older people:a retrospective cohort study

Aims: Older people with diabetes are susceptible to harm from hypoglycemia, however the consequences of hypoglycemia in older people with dementia are not known. We aimed to test association between hypoglycemia and serious adverse events in older patients with diabetes and dementia, and whether the consequences of hypoglycemia were affected by presence of dementia.  Materials and Methods: Cohort study using Clinical Practice Research Datalink in England (1997-2016). We selected participants, intervention (exposure) and follow-up to mirror two hypothetical target randomised controlled trials. Target trial 1’s exposure was hypoglycemia in patients with dementia. Target trial 2 examined adverse effects of hypoglycemia according to dementia status.We used Cox proportional hazard regression to estimate adjusted hazard ratios (aHR) for falls, fractures, cardiovascular events and mortality.  Results: In target trial 1, hypoglycemia was associated with an increased risk during 12 months follow-up of falls and fractures - aHR 1.94 (95% CI 1.67 to 2.24), cardiovascular events - aHR 2.00 (95% CI 1.61 to 2.48) and mortality - aHR 2.36 (95% CI 2.09 to 2.67).In target trial 2, presence of dementia was associated with increased risk of adverse events after hypoglycemia (12 months follow-up): falls & factures - aHR 1.72 (95% CI 1.51 to 1.96) and mortality - aHR 1.27 (95% CI 1.15 to 1.41), but had no effect on cardiovascular events - aHR 1.14 (95% CI 0.95 to 1.36).  Conclusions and Relevance: Hypoglycemia is associated with an early increased risk of serious adverse events in older people with diabetes and dementia