When it is not just DKA; diabetic ketoacidosis as a first presentation of pancreatic adenocarcinoma

Pancreatic cancer is the fourth leading cause of cancer related-deaths in the United States. Early symptoms of pancreatic cancer are nonspecific, and most cases are diagnosed at an advanced stage. DKA as a first presentation of pancreatic adenocarcinoma is a seldom reported condition. We present a case of a 59 year old female with type 2 diabetes, who presented to the emergency department with confusion, abdominal pain, polyuria and polydipsia. Laboratory workup showed a high anion gap metabolic acidosis and a blood glucose level of 419 mg/dl with positive serum ketones. She was diagnosed with DKA and admitted to the ICU. A CT abdomen/pelvis was performed to assess for pancreatic pathology as her DKA took longer time to resolve, it showed a pancreatic mass with multiple lesions in the liver. She had biopsies done which were positive for poorly differentiated pancreatic ductal adenocarcinoma. DKA occurs less commonly in patients with type 2 diabetes. Common precipitating factors for DKA in type 2 diabetes include medication noncompliance, infection, or possibly treatment with SGLT2 inhibitors. DKA as a first presentation of pancreatic cancer has been reported more with endocrine islet cell tumors but rarely with adenocarcinoma of the exocrine pancreas. Studies have shown that diabetes is an independent risk factor for development of pancreatic cancer. Other studies suggested that diabetes might be a result of pancreatic cancer or a paraneoplastic effect. One study suggested that diabetes associated with pancreatic cancer occurs at a resectable stage of the disease.     

Ketoacidosis at Diabetes Onset Is Still Frequent in Children and Adolescents: A multicenter analysis of 14,664 patients from 106 institutions

OBJECTIVE

We aimed at analyzing the frequency, clinical characteristics, and trends associated with the occurrence of diabetic ketoacidosis (DKA) at the onset of type 1 diabetes on the basis of long-term follow-up data.

RESEARCH DESIGN AND METHODS

A total of 106 pediatric diabetes centers in Germany and Austria participated in this study. Data from14,664 patients with type 1 diabetes collected between 1995 and 2007 were suitable for evaluation. DKA was defined and classified according to the International Society for Pediatric and Adolescent Diabetes consensus guidelines.

RESULTS

DKA was observed in 21.1% of patients. The frequency of DKA, including the severe form, remained unchanged throughout the 13-year observation period. The frequency of DKA was particularly striking among children <5 years of age (26.5%).

CONCLUSIONS

Ketoacidosis occurring at diabetes onset continues to be a difficult problem. Our data show no significant change in the frequency and magnitude of DKA over the last 13 years.Given that the incidence of type 1 diabetes is rising, and awareness of the disease is thus broadening, it is probably reasonable to expect a drop in the occurrence of diabetic ketoacidosis (DKA) at the onset of diabetes.By means of a computerized follow-up program for diabetic children called the Diabetes Prospective Documentation Initiative or Diabetes Patienten Verlaufsdokumenation (DPV), we analyzed the frequency and clinical characteristics of DKA occurring at the time of diabetes onset in order to ascertain whether a change in the frequency of DKA at diabetes onset was discernible over the last 13 years.     

Immunogenetic analysis suggests different pathogenesis for obese and lean African-Americans with diabetic ketoacidosis.

OBJECTIVE: When presenting with diabetic ketoacidosis (DKA), lean and obese patients differ in their subsequent clinical course. Although lean patients tend to remain insulin dependent, most obese patients recover endogenous insulin secretion and discontinue insulin therapy. The aim of this study was to determine whether obese African-American patients with DKA could be determined to have type 1 or type 2 diabetes based on insulin secretion or the presence of immunological and genetic markers. RESEARCH DESIGN AND METHODS: This was a prospective study that analyzed the clinical characteristics, insulin secretion indices, immunological markers (islet cell, GAD, ICA512, and insulin autoantibodies), and HLA susceptibility genes (DR/DQ) in 131 patients with DKA (77 obese and 54 lean), 51 obese patients with hyperglycemia but no DKA, and 25 nondiabetic subjects. All subjects were African-American. Beta-cell function was evaluated by the C-peptide response to glucagon (1 mg i.v.) within 48 h of resolution of DKA or hyperglycemia. RESULTS: The acute C-peptide response was lower in obese DKA patients (1.0+/-0.1 ng/ml) than in obese patients with hyperglycemia (1.7+/-0.2 ng/ml, P < 0.01), but was higher than that in lean DKA patients (0.2+/-0.1 ng/ml, both P < 0.01). The overall prevalence of autoantibodies in obese subjects with DKA (17%) and obese subjects with hyperglycemia (16%) was lower than that in lean subjects with DKA (65%, P < 0.01). Obese patients with hyperglycemia and positive autoantibodies had lower rates of insulin secretion than those without antibodies. Regardless of body weight, all DKA patients with GAD autoantibodies carried the DQB1*0201 allele. However, there were no significant differences in HLA distribution between the three patient groups. CONCLUSIONS: Our results indicate that most obese African-American patients with DKA have type 2 diabetes characterized by higher insulin secretion, the absence of autoimmune markers, and a lack of HLA genetic association. In contrast, most lean African-American patients with DKA have metabolic and immunological features of type 1 diabetes. At presentation, assessment of beta-cell function and determination of autoimmune markers allow for correct classification of diabetes in African-Americans with hyperglycemic crises.     

Diabetic Ketoacidosis and Related Events in the Canagliflozin Type 2 Diabetes Clinical Program

OBJECTIVE

This study assessed the incidence of serious adverse events of diabetic ketoacidosis (DKA) among patients with type 2 diabetes treated with canagliflozin.

RESEARCH DESIGN AND METHODS

All serious adverse events of DKA and related events (ketoacidosis, metabolic acidosis, and acidosis) from 17,596 patients from randomized studies of canagliflozin through 11 May 2015 were analyzed.

RESULTS

Serious adverse events of DKA and related events were reported in 12 patients (0.07%), including 4 (0.07%), 6 (0.11%), and 2 (0.03%) treated with canagliflozin 100 and 300 mg and comparator, respectively; corresponding incidence rates were 0.522, 0.763, and 0.238 per 1,000 patient-years, respectively. Most patients with DKA and related events had a blood glucose >300 mg/dL (16.7 mmol/L) at presentation of DKA, were on insulin, and had DKA-precipitating factors, including some with type 1 diabetes/latent autoimmune diabetes of adulthood.

CONCLUSIONS

DKA and related events occurred at a low frequency in the canagliflozin type 2 diabetes program, with an incidence consistent with limited existing observational data in the general population with type 2 diabetes.     

Spike in Diabetic Ketoacidosis Rates in Pediatric Type 2 Diabetes During the COVID-19 Pandemic

OBJECTIVEThe impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) on the incidence of new-onset type 2 diabetes and diabetic ketoacidosis (DKA) is unclear. It is unknown whether the coincidence of DKA noted in adult patients with type 2 diabetes is an issue for youth during the coronavirus disease 2019 pandemic.RESEARCH DESIGN AND METHODSA retrospective single-center medical record review was conducted in a large, urban children’s hospital of pediatric subjects presenting with new-onset type 2 diabetes between March and August of 2018 to 2020.RESULTSThe proportion of subjects presenting with new-onset type 2 diabetes in DKA dramatically increased in 2020 (9% in 2018, 3% in 2019, and 20% in 2020, P = 0.029).CONCLUSIONSIn 2020, youth with new-onset type 2 diabetes had a greater incidence of DKA at presentation than previously observed. Future studies should examine the impact of SARS-CoV2 exposure on the presentation of type 2 diabetes in all age-groups to inform better patient care.     

Economic impact of diabetic ketoacidosis in a multiethnic indigent population: analysis of costs based on the precipitating cause

OBJECTIVE: Diabetic ketoacidosis (DKA) is a common complication of diabetes. We analyzed the inpatient costs of treating DKA in a multiethnic, indigent population in Houston, Texas. RESEARCH DESIGN AND METHODS: We measured the cost of resources utilized for all patients admitted to our hospital with DKA from 1 January to 31 December 1998. We also analyzed their medical records to determine the factors that precipitated the episode of DKA and then grouped them into three categories: acute illnesses, noncompliance with diabetes treatment, and new-onset diabetes. The data were analyzed by one-way ANOVA. The Tukey-Kramer procedure was used for post hoc multiple comparisons. RESULTS: There were 167 admissions for DKA. The mean age was 40 +/- 13 years. The ethnic distribution was 49% African American, 32% Hispanic American, and 18% white. The total inhospital cost of treating DKA was $1,816,255. The mean cost per hospitalization was $10, 876 +/- 11,024. The frequency distribution by category of DKA-precipitating factor was 18% acute illness, 59% noncompliance, and 23% new onset. There were differences in mean cost of DKA associated with the three categories: $20,864 +/- 17,910 for acute illness, $11,863 +/- 8,701 for new onset, and $7,470 +/- 6,300 for noncompliance (P < 0.0001). The total cost for each category was $671,375 for acute illness, $694,082 for noncompliance, and $450,798 for new onset. CONCLUSIONS: DKA is an expensive complication among indigent, multiethnic diabetic patients. Although the mean cost per admission was lowest for DKA precipitated by noncompliance, this causal category was responsible in sum for the greatest portion of the economic burden.     

Important Dietary Considerations for Sodium-Glucose Cotransporter 2 Inhibitors

Sodium-glucose cotransporter 2 (SGLT2) inhibitors are a pharmacologic option for type 2 diabetes, and several benefits beyond glycemic lowering, including cardiovascular and renal, are associated with their use. However, some rare but serious potential adverse effects have been reported, including diabetic ketoacidosis (DKA) and euglycemic DKA. Certain dietary factors may increase the risk of SGLT2 inhibitor–associated ketoacidosis, such as low-carbohydrate and ketogenic diets, prolonged fasting, dehydration, and excess alcohol consumption. Clinicians should remain cognizant of precipitating factors; discuss modifiable risk factors with patients; and implement preventive strategies, such as withholding a SGLT2 inhibitor in situations associated with risk.     

Increase in Prevalence of Diabetic Ketoacidosis at Diagnosis Among Youth With Type 1 Diabetes: The SEARCH for Diabetes in Youth Study

OBJECTIVEWe previously reported a high (˜30%) but stable prevalence of diabetic ketoacidosis (DKA) at youth-onset diagnosis of type 1 diabetes (2002 and 2010). Given the changing demographics of youth-onset type 1 diabetes, we sought to evaluate temporal trends in the prevalence of DKA at diagnosis of type 1 diabetes from 2010 to 2016 among youth <20 years of age and evaluate whether any change observed was associated with changes in sociodemographic distribution of those recently diagnosed.RESEARCH DESIGN AND METHODSWe calculated prevalence of DKA within 1 month of type 1 diabetes diagnosis by year and evaluated trends over time (2010–2016) (n = 7,612 incident diabetes cases; mean [SD] age 10.1 [4.5] at diagnosis). To assess whether trends observed were attributable to the changing distribution of sociodemographic factors among youth with incident type 1 diabetes, we estimated an adjusted relative risk (RR) of DKA in relation to calendar year, adjusting for age, sex, race/ethnicity, income, education, health insurance status, language, season of diagnosis, and SEARCH for Diabetes in Youth Study site.RESULTSDKA prevalence increased from 35.3% (95% CI 32.2, 38.4) in 2010 to 40.6% (95% CI 37.8, 43.4) in 2016 (P_trend = 0.01). Adjustment for sociodemographic factors did not substantively change the observed trends. We observed a 2% annual increase in prevalence of DKA at or near diagnosis of type 1 diabetes (crude RR 1.02 [95% CI 1.01, 1.04] and adjusted RR 1.02 [95% CI 1.01, 1.04]; P = 0.01 for both).CONCLUSIONSPrevalence of DKA at or near type 1 diabetes diagnosis has increased from 2010 to 2016, following the high but stable prevalence observed from 2002 to 2010. This increase does not seem to be attributable to the changes in distribution of sociodemographic factors over time.     

Association of doctor specialty with diabetic patient risk of hospitalization due to diabetic ketoacidosis: a national population‐based study in Taiwan

Objectives Diabetic ketoacidosis (DKA) is a life‐threatening complication of diabetes mellitus, and its risks can be largely reduced by adequate and high‐quality ambulatory diabetic care. The aim of this study is to assess the risk and frequency of developing DKA in relation to the specialty of doctors who provide diabetes cares. Methods In searching for possible episodes of hospitalization due to DKA (ICD‐9‐CM: 250.1), we used a prospective cohort design in which 500 867 diabetic patients identified in the 1997 National Health Insurance (NHI) ambulatory care data set of Taiwan were linked to the 1997–2006 NHI inpatient claims data. The study subjects were categorized into four groups according to doctor specialty. A logistic regression model was used to assess the risk and frequency of DKA admission in relation to doctor's specialty. Results Compared with the patients routinely cared by endocrinologists, those not consistently cared by endocrinologists had significantly increased odds ratios (ORs) of DKA admission, ranging between 1.51 and 2.12. Moreover, the adjusted OR of the higher DKA admission frequency (≥0.133 times/person‐year) for the patients not regularly cared by endocrinologists was also significantly increased, between 4.45 and 6.93. Conclusions Doctor specialty significantly influenced the risk and frequency of DKA admission in diabetes patients in Taiwan. Local health care administrators and policy makers should therefore consider promoting the quality of diabetes care provided by non‐endocrinologists.     

Diabetic ketoacidosis

Diabetic ketoacidosis (DKA) is a form of a hyperglycemic emergency mainly characterized by the triad of hyperglycemia, ketosis, and anion gap metabolic acidosis. DKA may be the initial presentation in approximately 25-40 % of patients with type 1 diabetes. It may also occur in at least 34% of patients with type 2 diabetes. DKA has economic as well as medical implications. This review aims to explore and discuss diabetic ketoacidosis, its pathophysiology, clinical presentation, diagnosis, and management, including nuances in special populations such as pediatrics, obstetrics, and patients with chronic kidney disease.     

Pharmacologic treatment of the critically ill patient with diabetes

The pharmacologic approach to the management of DKA and HHNS involves the use of insulin, fluids, and electrolytes. Essential to the successful treatment of DKA and HHNS is a carefully planned post-intensive-care transition period. This period is based on the understanding that insulin therapy is never interrupted in patients with type 1 diabetes and the transition to insulin and/or oral hypoglycemic therapy in type 2 patients is strategically planned. The use of acute adjuvant insulin-glucose therapy in acute coronary syndromes and cardiac surgeries can result in decrease in overall morbidity and mortality in patients with diabetes. Ultimately, however, the major approaches to the treatment of diabetes is primary prevention of diabetes itself and the secondary prevention of complications through vigorous glucose control.     

老年糖尿病酮症酸中毒患者甲状腺激素水平变化研究

目的探讨老年糖尿病酮症酸中毒（DKA）患者甲状腺激素水平变化,为该类疾病患者的临床治疗提供依据。方法选择老年2型糖尿病患者共175例,分为DKA患者81例（DKA组）和无严重并发症的2型糖尿病患者94例（对照组）。检测两组治疗前后的血清甲状腺激素水平变化并分析。结果治疗前DKA组总三碘甲状腺氨酸（TT3）、总甲状腺素（TT4）、游离三碘甲状腺原氨酸（n）均显著低于对照组,两组游离四碘甲状腺原氨酸（FT3）、促甲状腺素（TSH）比较无统计学差异。DKA组治疗后m、Tr4、Fr4均显著升高,与治疗前相比有统计学差异,FT3和TSH较治疗前无显著差异。DKA组治疗后血清甲状腺激素水平与对照组治疗后相比无统计学差异。结论老年糖尿病合并DKA的患者可出现甲状腺激素水平降低,但常规治疗后恢复,因此应综合考虑,不可盲目加用甲状腺激素进行治疗。     

Recent trends in hospitalization for diabetic ketoacidosis in ontario children

OBJECTIVE: To investigate trends and geographic variation in diabetic ketoacidosis (DKA) hospitalization rates among children in Ontario from 1991 to 1999. RESEARCH DESIGN AND METHODS: Canadian Institute for Health Information (CIHI) data were used to identify 15,872 diabetes-related hospital admissions in children younger than 19 years in Ontario from 1991 to 1999. Of these, 5,008 admissions were because of DKA and 10,864 admissions were because of conditions other than DKA (non-DKA). Small area variation analysis was used to compare areas with high versus low DKA admission rates. RESULTS: There was a 19% relative decrease in the overall diabetes admission rate over the study period. Non-DKA admissions decreased by 29%, whereas DKA admissions remained stable. Total days of care decreased by 393 days per year for non-DKA admissions and by 99 days per year for DKA admissions. The average length of hospital stay decreased from 4.9 to 3.5 days for non-DKA admissions and from 4.5 to 3.2 days for DKA admissions. The fatality rate was 0.19% for non-DKA admissions and 0.18% for DKA admissions. Variation across geographic areas remained stable for DKA over the study period (Kendall's correlation coefficient 0.64, P = 0.017) with an average 3.7-fold difference between the lowest and highest regions. CONCLUSIONS: Increased ambulatory care efforts for children with type 1 diabetes in Ontario have successfully reduced non-DKA admission rates. However, DKA admission rates have remained stable. Geographic variation for DKA admissions is low, but the observed 3.7-fold difference is clinically important for a preventable complication with a significant potential for long-term morbidity and mortality. Prevention strategies are needed, particularly in areas identified with the highest rates.     

Medical Expenditures Associated With Diabetes Acute Complications in Privately Insured U.S. Youth

OBJECTIVE

To estimate medical expenditures attributable to diabetes ketoacidosis (DKA) and severe hypoglycemia among privately insured insulin-treated U.S. youth with diabetes.

RESEARCH DESIGN AND METHODS

We analyzed the insurance claims of 7,556 youth, age ≤19 years, with insulin-treated diabetes. The youth were continuously enrolled in fee-for-service health plans, and claims were obtained from the 2007 U.S. MarketScan Commercial Claims and Encounter database. We used regression models to estimate total medical expenditures and their subcomponents: outpatient, inpatient, and drug expenditures. The excess expenditures associated with DKA and severe hypoglycemia were estimated as the difference between predicted medical expenditures for youth who did/did not experience either DKA or severe hypoglycemia.

RESULTS

For youth with and without DKA, respectively, predicted mean annual total medical expenditures were $14,236 and $8,398 (an excess of $5,837 for those with DKA). The excess was statistically greater for those with one or more episodes of DKA ($8,455) than among those with only one episode ($3,554). Predicted mean annual total medical expenditures were $12,850 and $8,970 for youth with and without severe hypoglycemia, respectively (an excess of $3,880 for those with severe hypoglycemia). The excess was greater among those with one or more episodes ($5,929) than among those with only one ($2,888).

CONCLUSIONS

Medical expenditures for potentially preventable DKA and severe hypoglycemia in U.S. youth with insulin-treated diabetes are substantial. Improving the quality of care for these youth to prevent the development of these two complications could avert substantial U.S. health care expenditures.Diabetes ketoacidosis (DKA) and severe hypoglycemia are two common acute diabetes complications in youth. DKA, which results from absolute or relative insulin deficiency, can be the initial clinical presentation of both type 1 and type 2 diabetes or can occur in those with an established diabetes diagnosis. Severe hypoglycemia is a serious side effect of insulin treatment, especially for children and adolescents with type 1 diabetes. Despite substantial progress in diabetes management and care over the last 20 years (1), incidence and prevalence of these potentially preventable complications remain high (2,5). In 2006, among people in the U.S. with diabetes aged 0–17 years, 64% of the first-listed hospital discharge diagnoses included DKA (http://www.cdc.gov/diabetes/statistics/hosp/kidtable1.htm, accessed on 26 April 2010). An estimated 15–29% of youth with diabetes had DKA at the onset of diabetes (4–7). Among those aged <19 years with established type 1 diabetes, the overall incidence of DKA and severe hypoglycemia was estimated to be 8 and 19 per 100 patient-years, respectively (2).In addition to the risk for premature death and lower quality of life associated with these conditions, both DKA and severe hypoglycemia impose large economic burdens on the health care system (2,3,8,9). Medical expenses attributed to DKA and severe hypoglycemia have been estimated in diabetic adults (9–13), but similar estimates are not available for U.S. youth (age <20 years). We are aware of no studies that examine excess medical expenditures in youth experiencing recurrent DKA or severe hypoglycemia episodes.To evaluate the economic efficiency of programs aimed at improving quality of care and to establish health care policies for youth with diabetes, estimates of excess medical expenditures associated with these acute complications are needed. Thus, our study''s objectives were to 1) estimate the excess medical expenditures associated with DKA and severe hypoglycemia among youth with insulin-treated diabetes (ITDM) and 2) to examine the extent to which the excess expenditures are associated with the number of episodes of these complications.     

Methamphetamine-Induced Tachydysrhythmia in an Adolescent in Diabetic Ketoacidosis

BackgroundDiabetic ketoacidosis (DKA) is a common complication affecting patients with type 1 diabetes, and DKA is associated with dehydration and electrolyte abnormalities. Supraventricular tachycardia (SVT), although a common tachydysrhythmia in the pediatric population, remains a rare entity in patients presenting with DKA.Case ReportWe describe a case of first-time SVT in an adolescent patient with DKA and recent methamphetamine abuse, with both factors likely predisposing him to develop a tachydysrhythmia.Why Should an Emergency Physician Be Aware of This?SVT can be present in a patient who has concomitant recent stimulant intake and DKA. A trial of abortive therapy, such as adenosine, should be considered upon diagnosis.     

Recurrent diabetic ketoacidosis in inner-city minority patients: behavioral, socioeconomic, and psychosocial factors

OBJECTIVE

To conduct a bedside study to determine the factors driving insulin noncompliance in inner-city patients with recurrent diabetic ketoacidosis (DKA).

RESEARCH DESIGN AND METHODS

We analyzed socioeconomic and psychological factors in 164 adult patients with DKA who were admitted to Grady Hospital between July 2007 and August 2010, including demographics, diabetes treatment, education, and mental illness. The Patient Health Questionnaire-9 and the Short Form-36 surveys were used to screen for depression and assess quality of life.

RESULTS

The average number of admissions was 4.5 ± 7 per patient. A total of 73 patients presented with first-time DKA, and 91 presented with recurrent DKA; 96% of patients were African American. Insulin discontinuation was the leading precipitating cause in 68% of patients; other causes were new-onset diabetes (10%), infection (15%), medical illness (4%), and undetermined causes (3%). Among those who stopped insulin, 32% gave no reasons for stopping, 27% reported lack of money to buy insulin, 19% felt sick, 15% were away from their supply, and 5% were stretching insulin. Compared with first-time DKA, those with recurrent episodes had longer duration of diabetes (P < 0.001), were a younger age at the onset of diabetes (P = 0.04), and had higher rates of depression (P = 0.04), alcohol (P = 0.047) and drug (P < 0.001) abuse, and homelessness (P = 0.005). There were no differences in quality-of-life scores, major psychiatric illnesses, or employment between groups.

CONCLUSIONS

Poor adherence to insulin therapy is the leading cause of recurrent DKA in inner-city patients. Several behavioral, socioeconomic, psychosocial, and educational factors contribute to poor compliance. The recognition of such factors and the institution of culturally appropriate interventions and education programs might reduce DKA recurrence in minority populations.Diabetic ketoacidosis (DKA) is the most serious diabetic emergency in patients with type 1 and type 2 diabetes (1,2). DKA is the leading cause of mortality in children and young adults with type 1 diabetes, accounting for ~50% of deaths in diabetic individuals aged <24 years (3). The number of admissions with DKA in the U.S. is >130,000 per year and has shown an upward trend, with a 30% increase in the annual number of cases between 1995 and 2005 (4). Treatment of DKA uses a large number of resources, accounting for an estimated total cost of $2.4 billion annually (5). Observational studies in adult patients with diabetes list infectious complications as the most common precipitating factor for DKA (1,6,7), followed by discontinuation of or inadequate insulin therapy; trauma; medical and surgical illnesses, including pancreatitis, myocardial infarction, cerebrovascular accident, and general surgery; and drugs (8–11).In adult patients with type 1 diabetes, poor adherence to insulin therapy is reported as the major precipitating cause of DKA. Musey et al. (12), in a study of urban African Americans with DKA in 1995, reported that 75% of cases occurred in patients with known diabetes, and, of those patients, stopping insulin therapy was the precipitating cause in 67% of cases. Among patients who stopped insulin therapy, 50% reported a lack of money or transportation to obtain insulin, 21% stopped because of a lack of appetite, 14% stopped because of behavioral or psychological reasons, and 14% stopped because they did not know how to manage diabetes on sick days. Maldonado et al. (10) also found that noncompliance was responsible for 59% of cases of DKA in an inner-city hospital in Houston, Texas, in 1998. Over a decade ago, we reported that noncompliance with insulin treatment was responsible for 49% of DKA cases among urban blacks and for many patients having multiple admissions with DKA (7). Despite the high number of cases of DKA attributed to poor compliance, studies on causes of DKA and noncompliance have only been chart reviews; no studies have involved personal interviews with patients. Accordingly, we conducted a cross-sectional study to assess cultural, socioeconomic, and psychological factors associated with poor compliance resulting in recurrent admissions for DKA in inner-city patients.     

糖尿病性肝损害相关因素分析

目的：了解糖尿病及伴酮症或酮症（DK）或酮症酸中毒（DKA）时肝损害的情况，进一步探讨糖尿病肝损害的相关因素。方法：在354例糖尿病患者中，把有肝损害的52例分为有或无DK或DKA两组，做丙氨酸转氨酶（ALT），天冬氨酸转氨酶（AST）及总胆红素（TB）值的比较。把伴DK或DKA的57例分为有或无肝损害两组，观察肝损害与二氧化碳结合力（CO2CP），尿素氮（BUN），血糖（GLU）及血浆渗透浓度（OSM）水平的关系。结果：糖尿病肝损害的发生率为14．68％，伴DK或DKA时发生率增至29．82％；伴DK或DKA组ALT，AST，TB升高显著高于无DK或DKA组（P＜0．05）；伴DK或DKA者有肝损害组CO2CP明显低于无肝损害组；BUN，GLU，OSM明显高于无肝损害组，二组均有显著性差异（P＜0．01）。结论：酸中毒和脱水是引起糖尿病肝损害的重要因素，肝功能损害程度与糖尿病病情严重程度相关。     

1型糖尿病酮症酸中毒并发非甲状腺疾病病态综合征者3型脱碘酶mRNA水平研究

目的:探讨1型糖尿病(T1DM)合并酮症酸中毒(DKA)及正常甲状腺病态综合征(ESS)患者3型脱碘酶(D3) mRNA水平的变化及其发生机制.方法:T1DM并DKA及ESS患者28例,于确诊24 h内及DKA纠正后7d及14 d采血,选取同期住院的不伴感染、甲状腺疾病、缺氧、手术或禁食的同年龄同性别患者30例为对照组.采用放射免疫分析法检测血清T3、T4、FT3、FT4及TSH,采用Real-time PCR法测定血液D3 mRNA的表达水平.结果:DKA患者T3、FT3及FT4水平明显低于对照组,随着DKA的纠正,其水平逐渐回升,直至DKA后14d,FT3及FT4恢复至对照组水平,而T3仍未恢复至对照组水平.与之相对应,DKA者D3mRNA水平明显高于对照组,随着DKA的纠正,D3 mRNA水平逐渐下降,14 d仍未降至对照组水平.结论:D3 mRNA水平的变化可能是T1 DM合并DKA患者发生ESS的关键.     

Anaphylaxis-induced diabetic ketoacidosis

Allergic reactions and complications of diabetes mellitus are commonly seen in emergency departments and primary care settings. Although stress is a known contributor to the development of diabetic ketoacidosis (DKA), anaphylaxis-induced DKA has not previously been described. The case of a type 1 diabetic woman who presented with anaphylaxis secondary to seafood ingestion and subsequently developed DKA is reported. It was concluded that stress and counter-regulatory hormones released during anaphylaxis, as well as the treatment with epinephrine and glucocorticolds, precipitated DKA in this patient despite ongoing insulin and fluid therapy. Type 1 diabetic patients experiencing anaphylaxis may reguire prolonged periods of observation and measurement of serial blood glucose and urine ketones.