PRECIPITATING FACTORS AND CLINICAL FEATURES OF DIABETIC KETOACIDOSIS

vod: Dijabetička ketoacidoza (DKA) jedna je od najozbiljnijih akutnih komplikacija šećerne bolesti (ŠB). Pojedina istraživanja su pokazala da su infekcije precipitirajući čimbenik u polovice ispitanika. Nekoliko novijih istraživanja naglašava da je loše pridržavanje liječenja također česti uzrok DKA. Cilj: Identifi cirati najčešće precipitirajuće čimbenike za DKA u Republici Hrvatskoj. Ispitanici i postupci: Ovo retrospektivno multicentrično istraživanje uključivalo je bolesnike sa ŠB-om tipa 1 ili tipa 2 s dijagnozom DKA između 1. siječnja 2014. i 31. prosinca 2018. i liječenih u 5 različitih središta za liječenje ŠB-a: Dubrovnik, Našice, Split, Zagreb i Osijek. U analizu je uključena samo prve epizoda DKA. Pacijenti koji boluju od steroidnog ŠB-a i ŠB-a zbog endokrinih poremećaja kao što su akromegalija i Cushingov sindrom bili su isključeni. Rezultati: Istraživanjem je obuhvaćeno 160 bolesnika (55 % muškaraca), od kojih je 68% imalo ŠB tip 1. Srednja dob ispitanika bila je 42 godine (od 18 do 89). Najčešći uzrok DKA bila je infekcija (57 %), zatim slabo kontrolirani ŠB (37 %) i prva prezentacija ŠB-a (9 %), dok je u 7% bolesnika DKA bila uzrokovana ostalim uzrocima kao što su kvar inzulinske pumpe, moždani ili srčani udar. U skupini bolesnika s infekcijama najčešće su bile infekcije mokraćnog sustava (30 %), probavne infekcije (30 %) i infekcije respiratornog trakta (19 %), dok je 21 % bolesnika imalo druge izvore infekcije. U 36 ovih bolesnika uz infekciju je bio prisutan i prethodno loše kontroliran ŠB, a u 12 % DKA uzrokovana infekcijom bila je prvo očitovanje bolesti. U bolesnika sa ŠB-om tipa 2 infekcije su češće bile uzrok DKA nego u bolesnika sa ŠB-om tipa 1 (P < 0,05). U bolesnika sa ŠB-om tipa 1, slabo regulirana glikemija je češće uzrok DKA (31%) nego u bolesnika sa ŠB-om tipa 2 (18 %). Zaključak: Najčešći precipitirajući čimbenici za razvoj DKA su infekcije i loša regulacija ŠB-a. Potrebna je bolja edukacija bolesnika o važnosti redovite primjene inzulina i korekcije terapije tijekom akutne bolesti.Introduction: Diabetic ketoacidosis (DKA) is one of the most serious acute complications of diabetes mellitus (DM). In some studies, infections have been found to be a precipitating factor in more than half of the subjects. On the other hand, several recent studies emphasize that poor treatment adherence is also a common cause of DKA. Objective: To identify the most common precipitating factors for DKA in Croatia. Patients and Methods: This retrospective, multicenter study included DM type 1 or DM type 2 patients diagnosed with DKA between January 1, 2014 and December 31, 2018, and treated in 5 different DM treatment centers, i.e., Dubrovnik, Našice, Split, Zagreb and Osijek. Only the fi rst episode of DKA was included in the analysis. Patients receiving steroids and DM due to endocrine disorders such as acromegaly and Cushing\u27s syndrome were excluded. Results: The study included 160 patients (55% of men), of whom 68% had DM type 1. The mean age of the respondents was 42 (18-89) years. The most common cause of DKA was infection (57%), followed by poorly controlled DM (37%) and fi rst presentation of DM (9%), while in 7% of patients DKA was due to other causes such as insulin pump failure, stroke or myocardial infarction. In the group of patients with infections, urinary tract infections (30%), gastrointestinal infections (30%) and respiratory tract infections (19%) were most common, whereas 21% of patients had other sources of infection. In 36% of these patients, the infection was associated with previously poorly controlled diabetes, and in 12% of them, DKA caused by the infection was the fi rst manifestation of the disease. In patients with type 2DM, infections were more often the cause of DKA than in patients with type 1DM (p<0.05).Poorly controlled glycemia appeared to be a more frequent cause of DKA in patients with type 1 DM (31%) than in patients with type 2 DM (18%). Conclusion: The most common precipitating factors for the development of DKA were infections and poor diabetes management. Better education of patients about the importance of regular insulin administration and correction of therapy in acute illness could reduce the risk of DKA

PRECIPITATING FACTORS AND CLINICAL FEATURES OF DIABETIC KETOACIDOSIS

vod: Dijabetička ketoacidoza (DKA) jedna je od najozbiljnijih akutnih komplikacija šećerne bolesti (ŠB). Pojedina istraživanja su pokazala da su infekcije precipitirajući čimbenik u polovice ispitanika. Nekoliko novijih istraživanja naglašava da je loše pridržavanje liječenja također česti uzrok DKA. Cilj: Identifi cirati najčešće precipitirajuće čimbenike za DKA u Republici Hrvatskoj. Ispitanici i postupci: Ovo retrospektivno multicentrično istraživanje uključivalo je bolesnike sa ŠB-om tipa 1 ili tipa 2 s dijagnozom DKA između 1. siječnja 2014. i 31. prosinca 2018. i liječenih u 5 različitih središta za liječenje ŠB-a: Dubrovnik, Našice, Split, Zagreb i Osijek. U analizu je uključena samo prve epizoda DKA. Pacijenti koji boluju od steroidnog ŠB-a i ŠB-a zbog endokrinih poremećaja kao što su akromegalija i Cushingov sindrom bili su isključeni. Rezultati: Istraživanjem je obuhvaćeno 160 bolesnika (55 % muškaraca), od kojih je 68% imalo ŠB tip 1. Srednja dob ispitanika bila je 42 godine (od 18 do 89). Najčešći uzrok DKA bila je infekcija (57 %), zatim slabo kontrolirani ŠB (37 %) i prva prezentacija ŠB-a (9 %), dok je u 7% bolesnika DKA bila uzrokovana ostalim uzrocima kao što su kvar inzulinske pumpe, moždani ili srčani udar. U skupini bolesnika s infekcijama najčešće su bile infekcije mokraćnog sustava (30 %), probavne infekcije (30 %) i infekcije respiratornog trakta (19 %), dok je 21 % bolesnika imalo druge izvore infekcije. U 36 ovih bolesnika uz infekciju je bio prisutan i prethodno loše kontroliran ŠB, a u 12 % DKA uzrokovana infekcijom bila je prvo očitovanje bolesti. U bolesnika sa ŠB-om tipa 2 infekcije su češće bile uzrok DKA nego u bolesnika sa ŠB-om tipa 1 (P < 0,05). U bolesnika sa ŠB-om tipa 1, slabo regulirana glikemija je češće uzrok DKA (31%) nego u bolesnika sa ŠB-om tipa 2 (18 %). Zaključak: Najčešći precipitirajući čimbenici za razvoj DKA su infekcije i loša regulacija ŠB-a. Potrebna je bolja edukacija bolesnika o važnosti redovite primjene inzulina i korekcije terapije tijekom akutne bolesti.Introduction: Diabetic ketoacidosis (DKA) is one of the most serious acute complications of diabetes mellitus (DM). In some studies, infections have been found to be a precipitating factor in more than half of the subjects. On the other hand, several recent studies emphasize that poor treatment adherence is also a common cause of DKA. Objective: To identify the most common precipitating factors for DKA in Croatia. Patients and Methods: This retrospective, multicenter study included DM type 1 or DM type 2 patients diagnosed with DKA between January 1, 2014 and December 31, 2018, and treated in 5 different DM treatment centers, i.e., Dubrovnik, Našice, Split, Zagreb and Osijek. Only the fi rst episode of DKA was included in the analysis. Patients receiving steroids and DM due to endocrine disorders such as acromegaly and Cushing\u27s syndrome were excluded. Results: The study included 160 patients (55% of men), of whom 68% had DM type 1. The mean age of the respondents was 42 (18-89) years. The most common cause of DKA was infection (57%), followed by poorly controlled DM (37%) and fi rst presentation of DM (9%), while in 7% of patients DKA was due to other causes such as insulin pump failure, stroke or myocardial infarction. In the group of patients with infections, urinary tract infections (30%), gastrointestinal infections (30%) and respiratory tract infections (19%) were most common, whereas 21% of patients had other sources of infection. In 36% of these patients, the infection was associated with previously poorly controlled diabetes, and in 12% of them, DKA caused by the infection was the fi rst manifestation of the disease. In patients with type 2DM, infections were more often the cause of DKA than in patients with type 1DM (p<0.05).Poorly controlled glycemia appeared to be a more frequent cause of DKA in patients with type 1 DM (31%) than in patients with type 2 DM (18%). Conclusion: The most common precipitating factors for the development of DKA were infections and poor diabetes management. Better education of patients about the importance of regular insulin administration and correction of therapy in acute illness could reduce the risk of DKA

Age-dependent and sex-dependent disparity in mortality in patients with adrenal incidentalomas and autonomous cortisol secretion: an international, retrospective, cohort study.

BACKGROUND The association between cortisol secretion and mortality in patients with adrenal incidentalomas is controversial. We aimed to assess all-cause mortality, prevalence of comorbidities, and occurrence of cardiovascular events in uniformly stratified patients with adrenal incidentalomas and cortisol autonomy (defined as non-suppressible serum cortisol on dexamethasone suppression testing). METHODS We conducted an international, retrospective, cohort study (NAPACA Outcome) at 30 centres in 16 countries. Eligible patients were aged 18 years or older with an adrenal incidentaloma (diameter ≥1 cm) detected between Jan 1, 1996, and Dec 31, 2015, and availability of a 1 mg dexamethasone suppression test result from the time of the initial diagnosis. Patients with clinically apparent hormone excess, active malignancy, or follow-up of less than 36 months were excluded. Patients were stratified according to the 0800-0900 h serum cortisol values after an overnight 1 mg dexamethasone suppression test; less than 50 nmol/L was classed as non-functioning adenoma, 50-138 nmol/L as possible autonomous cortisol secretion, and greater than 138 nmol/L as autonomous cortisol secretion. The primary endpoint was all-cause mortality. Secondary endpoints were the prevalence of cardiometabolic comorbidities, cardiovascular events, and cause-specific mortality. The primary and secondary endpoints were assessed in all study participants. FINDINGS Of 4374 potentially eligible patients, 3656 (2089 [57·1%] with non-functioning adenoma, 1320 [36·1%] with possible autonomous cortisol secretion, and 247 [6·8%] with autonomous cortisol secretion) were included in the study cohort for mortality analysis (2350 [64·3%] women and 1306 [35·7%] men; median age 61 years [IQR 53-68]; median follow-up 7·0 years [IQR 4·7-10·2]). During follow-up, 352 (9·6%) patients died. All-cause mortality (adjusted for age, sex, comorbidities, and previous cardiovascular events) was significantly increased in patients with possible autonomous cortisol secretion (HR 1·52, 95% CI 1·19-1·94) and autonomous cortisol secretion (1·77, 1·20-2·62) compared with patients with non-functioning adenoma. In women younger than 65 years, autonomous cortisol secretion was associated with higher all-cause mortality than non-functioning adenoma (HR 4·39, 95% CI 1·93-9·96), although this was not observed in men. Cardiometabolic comorbidities were significantly less frequent with non-functioning adenoma than with possible autonomous cortisol secretion and autonomous cortisol secretion (hypertension occurred in 1186 [58·6%] of 2024 patients with non-functioning adenoma, 944 [74·0%] of 1275 with possible autonomous cortisol secretion, and 179 [75·2%] of 238 with autonomous cortisol secretion; dyslipidaemia occurred in 724 [36·2%] of 1999 patients, 547 [43·8%] of 1250, and 123 [51·9%] of 237; and any diabetes occurred in 365 [18·2%] of 2002, 288 [23·0%] of 1250, and 62 [26·7%] of 232; all p values <0·001). INTERPRETATION Cortisol autonomy is associated with increased all-cause mortality, particularly in women younger than 65 years. However, until results from randomised interventional trials are available, a conservative therapeutic approach seems to be justified in most patients with adrenal incidentaloma. FUNDING Deutsche Forschungsgemeinschaft, Associazione Italiana per la Ricerca sul Cancro, Università di Torino