Acidosis: The Prime Determinant of Depressed Sensorium in Diabetic Ketoacidosis

OBJECTIVE — The etiology of altered sensorium in diabetic ketoacidosis (DKA) remains unclear. Therefore, we sought to determine the origin of depressed consciousness in DKA. RESEARCH DESIGN AND METHODS — We analyzed retrospectively clinical and biochemical data of DKA patients admitted in a community teaching hospital. RESULTS — We recorded 216 cases, 21 % of which occurred in subjects with type 2 diabetes. Mean serum osmolality and pH were 304 31.6 mOsm/kg and 7.14 0.15, respectively. Acidosis emerged as the prime determinant of altered sensorium, but hyperosmolarity played a synergistic role in patients with severe acidosis to precipitate depressed sensorium (odds ratio 2.87). Combination of severe acidosis and hyperosmolarity predicted altered consciousness with 61 % sensitivity and 87 % specificity. Mortality occurred in 0.9 % of the cases. CONCLUSIONS — Acidosis was independently associated with altered sensorium, but hy-perosmolarity and serum “ketone ” levels were not. Combination of hyperosmolarity and acidosis predicted altered sensorium with good sensitivity and specificity. Diabetes Care 33:1837–1839, 2010 D iabetic ketoacidosis (DKA) is fre-quently associated with alteredmental status, which is correlated with the severity of the disease and prog-nosis (1). However, the etiology of de-pressed sensorium in DKA remains uncertain and controversial (2,3). Puta-tive factors in the pathogenesis of diabetic ketoacidotic coma include cerebral hypo-perfusion due to circulatory collapse and cerebral thrombosis (4), reduced cerebral glucose and oxygen utilization (1,5), aci-dosis (6,7), hyperosmolarity (8,9), and direct toxic effect of ketone bodies (2). Cerebral edema remains an important precipitant of altered consciousness in DKA, especially in children. Different studies have yielded con-flicting results regarding the role of these etiologic factors in the pathogenesis of al-tered mentation in patients with DKA. Hence, the origin of clouded sensorium in DKA remains to be fully elucidated. We undertook to study the etiology of de-pressed consciousness in patients admit-ted with DKA at the Regional Medica

Prevalence and risk factors for diabetes and diabetic retinopathy: results from the Nigeria national blindness and visual impairment survey.

BACKGROUND: In Nigeria, urbanisation and increasing life expectancy are likely to increase the incidence of non-communicable diseases. As the epidemic of diabetes matures, visual loss from diabetic retinopathy (DR) will increase unless mechanisms for early detection and treatment improve, and health systems respond to the growing burden of non-communicable diseases. METHODS: A nationally-representative population-based sample of 13,591 participants aged ≥40 years selected by multistage-stratified-cluster-random-sampling with probability-proportional-to-size procedures were examined in 305 clusters in Nigeria between January 2005 to June 2007. All were asked about history of diabetes and underwent basic eye examination. Visual acuity (VA) was measured using logMAR E-chart. Participants with VA11.1mmol/l or had DR. Data in the subsample were used to estimate the prevalence and to analyse risk factors for diabetes and DR using multivariable logistic regression. Additional information on the types of DR was obtained from participants not in the subsample. RESULTS: In the subsample, 164 participants were excluded due to missing data; and 1,595 analysed. 52/1,595 had diabetes, a prevalence of 3.3% (95%CI 2.5-4.3%); and 25/52(48%) did not know. Media opacity in 8/52 precluded retinal examination. 9/44(20.5%) had DR. Higher prevalence of diabetes was associated with urban residence (Odds ratio [OR]1.87) and overweight/obesity (OR3.02/4.43 respectively). Although not statistically significant, DR was associated with hypertension (OR3.49) and RBG>15.0mmol/L (OR8.10). Persons with diabetes had 3 times greater odds of blindness. Of 11,832 other participants in the study sample, 175(1.5%) had history of diabetes; 28 had DR. Types of DR (total=37) included 10.8% proliferative, 51.4% macular oedema. CONCLUSION: The age-adjusted prevalence of diabetes in Nigeria was 3.25% (95%CI 2.50-4.30) and over 10% of people with diabetes aged ≥40 years had sight-threatening-DR. These data will enable the development of better public health strategies for the control of diabetes and planning services for DR to prevent vision loss

Impact of an intensive lifestyle intervention on use and cost of medical services among overweight and obese adults with type 2 diabetes: the action for health in diabetes

OBJECTIVE: To assess the relative impact of an intensive lifestyle intervention (ILI) on use and costs of health care within the Look AHEAD trial. RESEARCH DESIGN AND METHODS: A total of 5,121 overweight or obese adults with type 2 diabetes were randomly assigned to an ILI that promoted weight loss or to a comparison condition of diabetes support and education (DSE). Use and costs of health-care services were recorded across an average of 10 years. RESULTS: ILI led to reductions in annual hospitalizations (11%, P = 0.004), hospital days (15%, P = 0.01), and number of medications (6%, P \u3c 0.001), resulting in cost savings for hospitalization (10%, P = 0.04) and medication (7%, P \u3c 0.001). ILI produced a mean relative per-person 10-year cost savings of $5,280 (95% CI 3,385-7,175); however, these were not evident among individuals with a history of cardiovascular disease. CONCLUSIONS: Compared with DSE over 10 years, ILI participants had fewer hospitalizations, fewer medications, and lower health-care costs