Group 1: Patients who were admitted in the study centre with age greater than 13 years and who were diagnosed to have diabeticketoacidosis at the time of admission based on the following criteria: serum glucose >13.9 mmol/L (>250 mg/dL, enzymatic method), serum bicarbonate concentration <18 mmol/L, arterial pH <7.30 (selective ion exchange method), and ketonemia (3 mmol/L) and overt or significant ketonuria (more than 2+ on standard urine sticks). Informed consent was obtained from the patients and/or the closest relative.
Abstract: DiabeticKetoacidosis (DKA) is one of the most serious acute complications of diabetes mellitus. The mortality rate remains high in developing countries and among misdiagnosed and treated patients. Therefore targeting early diagnosis and effective treatment programs is vital to save the life of patients. The aim of the study is to assess diabeticketoacidosis treatment outcome and associated factors among adult patients at Adama Hospital Medical College emergency department and medical wards, Oromia region, Ethiopia. Cross sectional study based on record review of 357 adult diabeticketoacidosispatients was selected using simple random sampling. Data was collected using checklist from medical registrations. The data was entered and analyzed using SPSS version 20 and EPI-info version 7 statistical packages. Majority of the patients (65.30%) had two or more episodes of diabeticketoacidosis and the main reasons for recurrent diabeticketoacidosis were infectious illness (69.50%) and insulin discontinuation (14.80%). Regarding treatment outcomes of diabeticketoacidosispatients, majority of them (84.90%) discharged with improved. Those diabeticketoacidosispatients treated with more than six liters fluid replacement in the 1st 24 hours had better treatment outcome by two times as compared to less than three liters fluid replacement (AOR=2.41 (1.58-10.02). Similarly, those patients who got more than sixty international unit insulin doses in the 1st 24hrs had better treatment outcome by ten times (AOR=10.68 (3.88- 20.64)) when compared to less than forty international unit insulin administration. In addition, DKA patients who got supplemental potassium showed five times treatment outcome improvement (AOR= 5.30 (2.11-13.32) than for those potassium replacement was not done. Even if majority of diabeticketoacidosispatients treated at Adama Hospital Medical College emergency room and medical wards were discharged with improvement, early treatment of infection, ample fluid replacement and insulin dose adjustment during illness need to be encouraged.
complication rate of 12% in diabeticpatients after TKA. In that series, the rate of deep joint infection in diabeticpatients was 10 times higher than the reported incidence of sepsis in non-diabeticpatients, therefore they suggested the use of anti- biotic-impregnated cement. Chiu et al. 15 performed a prospective randomized study to evaluate the role of cefuroxime-impregnated cement in the prevention of deep infection at primary TKA in patients with diabetes. They found no cases of deep infection in the group with cefuroxime- impregnated cement compared with a deep infection rate of 13.5% in the control group, and concluded that cefuroxime-impregnated cement was effective in the prevention of deep infection in patients with diabetes and suggested routine addition of cefuroxime. Its thermal stability and biological effectiveness in cement as well as good clinical result have been well documented, there- fore we have routinely been using cefuroxime- impregnated cement for primary TKA, vindicating the idea that prophylactic use of antibiotic bone cement should be the standard of practice for primary TKA. 38 Meding et al. also added cefuroxime to cement and reported a deep infection rate of 1.2% in diabeticpatients and 0.7% in nondiabetic patients, which are comparable with ours. In their study, all deep infections occurred in patients with insulin-dependent diabetes, whereas all deep infections in the current study occurred in patients who were treated with oral hypoglycemics (Table 8). Therefore, diabetes-related factors appear to have little influence on the rate of deep infection. A higher than expected aseptic loosening rate in Table 9. Statistical Analysis of the Relationships between Preoperative Factors and Postoperative Complications
It has been estimated that up to 20% of all cataract surgery is .  Many such patients have pre- existing diabetic retinopathy (DR) at the time of cataract surgery. Cataract in diabetes patients reduces their visual acuity (VA), renders adequate examination of the retina more difficult or sometimes impossible, and makes photocoagulation of DR more difficult. Therefore, it is important to perform cataract surgery for visual rehabilitation. Studies have reported the progression of retinopathy after extra capsular cataract extraction (ECCE)  and suggested to delay ract surgery especially in patients with more advanced However, besides visual rehabilitation, a substantial percentage of diabetics require lens extraction to permit proper diagnosis and treatment of retinopathy. Earlier t extraction in diabeticpatients, before macular oedema develops, may help stabilize retinopathy-associated macular
Aim: Review of presentation, management and outcome of patients admitted with DiabeticKetoacidosis (DKA) to an emergency department short stay unit with expedited discharge. Methods: All admitted patients with a dis- charge diagnosis of “DiabeticKetoacidosis”, were identified by the file audit- ing section in the Emergency Department. Data obtained from the medical records were collected using an explicit chart review from January 2012 to June 2013. Data included clinical monitoring, investigations performed, the type and amount of intravenous fluids given, the insulin regime, potassium supplementation and outcome. Results: Out of a total of 120 patients labelled as DKA or hyperglycaemia on arrival, hundred patients fulfilled the criteria for DKA. In the population studied the mean age was 25 years with a male predominance. Eighty-two patients suffered from Type 1 Diabetes Mellitus (T1DM) whilst eighteen patients had Type 2 Diabetes Mellitus (T2DM). Six- teen patients were newly diagnosed during the present admission. Seventy-six (76%) patients were on insulin. The insulin regimen and potassium supple- mentation were followed as per protocol in all patients. All the patients except one were given intravenous fluid according to protocol. Parameters were mo- nitored adequately except fluid input and output monitoring. The median length of stay in the short stay unit was 1.5833 days. There was no return visit within one week of discharge. Conclusion: The median length of stay was short and there were no documented complications or deaths during the stay. There was poor compliance with documentation of fluid input and out- put. In this population, the short stay model of care appeared to be safe and efficient.
The superior outcomes associated with vitrified day-5 blastocysts may be related to the fact that many of the day- 6 blastocysts were delayed in development, suggesting that they were of inferior quality. In the case of expanded good quality day 6 blastocysts, damage could still be explained by an increase in number of blastomeres, increase in their metabolic activity and an increase in blas- tocoele expansion. Any of these factors could increase the likelihood of inadequate vitrification, ice crystal forma- tion, and cryodamage [36,37]. Therefore, embryos that undergo blastulation on day 5 would better be vitrified on day 5, while embryos delayed in development may be allowed to develop to day 6 until vitrified. The rate of development and the degree of expansion are more likely to affect the outcome than the day of vitrification [13,36]. After all, transferred vitrified embryos will benefit from a better endometrial synchrony, which may dampen nega- tive effects from cryostorage .
This was a prospective cohort study, which was conducted in the department of obstetrics and gynaecology, Mahatma Gandhi Medical College and Research Institute Hospital, a tertiary care hospital. The Institutional Human Ethics Committee approved this study. The study involved antenatal mothers and neonates. Study period was from December 2016 to May 2018. The pregnant women who were fulfilling the inclusion and exclusion criteria and willing to participate in the study were recruited. Written and informed consent was obtained from all patients who participated in the study. All related data were collected and entered into the proforma sheet. The study included women with singleton pregnancy with gestational age of 37-42 weeks with vertex presentation and adequate pelvis and excluded women with fetal anomalies, rupture of membranes for > 12 hours, chorioamnionitis, uterine scar and antepartum haemorrhage.
Diabeticketoacidosis (DKA) is a preventable but serious complication of type 1 diabetes and carries a mortality rate of 0.3 – 0.5% in developed economies and much higher in developing economies (about 10%). 1,2 It occurs due to an interplay between insulin (de ﬁ ciency) and counter-regulatory hormones (excess). The former leads to hyperglycemia and ketosis, while the latter (epinephrine, cortisol and growth hormone) released in response to stress, aggravates hyperglycemia by blocking the action of insulin and enhancing glycogenolysis in the liver. 3 When blood glucose levels exceed the renal threshold (180mg/dL), glycosuria occurs. The resultant osmotic diuresis leads to volume depletion and dehydration, which activates the renin-angiotensin-aldoster- one axis and also triggers the release of counter-regulatory hormones. These hormones act towards preserving the intravascular volume. Vomiting, due to stimulation of chemoreceptor trigger zone by hydrogen ions and ketones, further aggravates volume loss and dehydration leading to a vicious cycle.
Another interesting outcome was the shorter duration of hospitaliza- tion for patients treated on medicine wards, despite the fact that all other outcomes were not significantly different. Two previous studies discussing DKA treatment with sub- cutaneous insulin on medicine wards had baseline characteristics that were fairly similar but slightly higher initial blood glucose and lower bicarbonate levels. 9,10 These patients
METHODS: Development involved systematic review of published liter- ature by a multidisciplinary team. Implementation included multidis- ciplinary feedback, hospital-wide education, daily team huddles, and development of computer decision support and electronic order sets. RESULTS: Pathway-based order sets forced clinical pathway adherence; yet, variations in care persisted, requiring ongoing iterative review and pathway tool adjustment. Quality improvement measures have identi ﬁ ed barriers and informed subsequent adjustments to interventions. We compared 281 patients treated postimplementation with 172 treated preimplementation. Our most notable ﬁ ndings included the following: (1) monitoring of serum potassium concentrations identi ﬁ ed unanticipated hypokalemia episodes, not recognized before standard work implementation, and earlier addition of potassium to ﬂ uids resulted in a notable reduction in hypokalemia; (2) improvements in insulin infusion management were associated with reduced duration of ICU stay; and (3) with overall improved DKA management and education, cerebral edema occurrence and bicarbonate use were reduced. We continue to convene quarterly meetings, review cases, and process ongoing issues with system-based elements of implementing the recommendations.
Risk factors are young children who are less than 2 years, delay in diagnosis of DM, poor diabetes control, previous episodes of DKA, missed insulin injections etc [7, 9, 14].Complications of DKA include inadequate rehydration, hypoglycaemic and hypokalemia which is commonly found and cerebral oedema, pulmonary oedema. The serious and most frequent seen complication in the paediatric population is cerebral oedema .The severity of DKA is categorized by the degree of acidosis which is given below Table 2 .
From the above study we conclude that there had been an increase in the patients with acute onset of symptoms now. Hypertension has emerged as an independent risk factor for CVT in this study which was to be given due importance because many of the recent studies showed an increased prevalence of hypertension in Indian population which can also probably account for increased incidence of CVT. Our study also emphasized that the prognosis of CVT was becoming more and more favorable.
A questionnaire was used to collect data about clinical status, such as type of diabetes, duration of diabetes, treatment category (insulin therapy, oral agents, and diet), presence of complications of diabetes according to medical records (including retinopathy, nephropathy, presence of comorbidity such as hypertension, ischemic heart disease, dyslipidemia), previous history of DFU, the length of hospitalization, baseline laboratory data (including HbA 1c and blood sugar), grade of foot ulcer, and behavioral factors, including cur- rent smoking (daily and occasional smokers) and body mass index (BMI). Please note: foot ulcer was graded according to Wagner’s classification: Grade 0, high-risk foot; Grade 1, superficial ulcer; Grade 2, deep ulcer penetrating to tendon, bone, or joint; Grade 3, deep ulcer with abscess
but to our knowledge, this association with managed care has not been described. In our population, a child was classified as managed care if all claims were listed as such, including before and after DKA events. Therefore, this association cannot reflect children switching to managed care after DKA events as a means to prevent recurrence. However, we cannot rule out that patients deemed high risk for other reasons were enrolled proactively in managed care at time of diagnosis. Further discussion with CCS administrators is needed to explore this and other potential explanations for the association between managed care and DKA hospitalizations.
Peptic ulcer perforation is one of the most common perforation in asian countries and is still in era of proton pump inhibitors. peptic ulcer disease can be divided into gastric and duodenal ulcers peptic ulcer perforation the bacteria released into the peritoneal cavity following perforation of a hollow viscus cause secondary peritonitis the morbidity and mortality associated with the presence of enterococcus. the prospective factors determining the outcome were studied such as age, sex, stage of presentation, co morbities, renal failure, use of nsaids ,multiple addiction and physical factors such as heart rate ,blood pressure, size and site of perforation ,amount of contamination and investigations ,days stay and complications were evaluated. Assessment of these factors at presentation can lead to identification of patients in need of intensive care and early aggressive surgical steps to decrease morbidity and mortlity were studied.60 patients with perforative peritonitis presented to the emergency department were included and studied. detailed history & clinical examination performed, routine blood investigation were done followed by the use of appropriate diagnostic procedures such as x-ray erect abdomen, with additional help of abdominal ultrasound and abdominal ct scan. this study concluded that factors causing adverse outcome in patients were identified as pre operative renal failure, multiple addictions ,peritoneal contamination, ,size of perforation were known to cause significant mortality and morbidity in this study.
Blood gas analysis is a commonly used diag- nostic tool to evaluate the partial pressure and acid-base content in blood, so as to explain the pathological mechanisms of respiratory, circu- latory and metabolic disorders, monitor the severity and progression of cardiopulmonary diseases, and assess the response of patients from certain therapeutic interventions . Blood gas analysis can be performed by blood taken from anywhere in the circulatory system (arteries, veins, or capillaries) . ABG analy- sis is the best way to assess the severity of acute or chronic disease, primary or secondary disease, as well as metabolic or respiratory dis- orders . A major method for preliminary assessment of the severity of DKA and the treatment efficacy is using ABG analysis to measure the pH and bicarbonate . However, there is growing evidence showing that VBG analysis can be used as an alternative to ABG analysis . Kelly et al. reported that the weighted mean difference between arterial and venous pH values in DKA patients was 0.02 pH units (95% range: -0.009 to +0.021 pH units), and the weighted mean difference between arterial and venous bicarbonates was -1.88 mEq/L, suggesting that the arterial and venous pH values are consistent and clinically inter- Table 5. AUC of blood gas analysis indices
Durvalumab is a programmed cell death ligand 1 inhibitor, which is now approved in Australia for use in non-small- cell lung and urothelial cancers. Autoimmune diabetes is a rare immune-related adverse effect associated with the use of immune checkpoint inhibitor therapy. It is now being increasingly described reflecting the wider use of immune checkpoint inhibitor therapy. We report the case of a 49-year-old female who presented with polyuria, polydipsia and weight loss, 3 months following the commencement of durvalumab. On admission, she was in severe diabeticketoacidosis with venous glucose: 20.1 mmol/L, pH: 7.14, bicarbonate 11.2 mmol/L and serum beta hydroxybutyrate: >8.0 mmol/L. She had no personal or family history of diabetes or autoimmune disease. Her HbA1c was 7.8% and her glutamic acid decarboxylase (GAD) antibodies were mildly elevated at 2.2 mU/L (reference range: <2 mU/L) with negative zinc transporter 8 (ZnT8) and islet cell (ICA) antibodies. Her fasting C-peptide was low at 86 pmol/L (reference range: 200–1200) with a corresponding serum glucose of 21.9 mmol/L. She was promptly stabilised with an insulin infusion in intensive care and discharged on basal bolus insulin. Durvalumab was recommenced once her glycaemic control had stabilised. Thyroid function tests at the time of admission were within normal limits with negative thyroid autoantibodies. Four weeks post discharge, repeat thyroid function tests revealed hypothyroidism, with an elevated thyroid-stimulating hormone (TSH) at 6.39 mIU/L (reference range: 0.40–4.80) and low free T4: 5.9 pmol/L (reference range: 8.0–16.0). These findings persisted with repeat testing despite an absence of clinical symptoms. Treatment with levothyroxine was commenced after excluding adrenal insufficiency (early morning cortisol: 339 nmol/L) and hypophysitis (normal pituitary on MRI).
A 55-year-old nonsmoking unmedicated black woman without past surgical or medical history apart from mild untreated hypertension presented with deteriorated general condition, lethargy, and confusion. There was no personal or family history of thrombosis. A few weeks prior to admission, she had polyuria, polydipsia, and polyphagia. Laboratory findings mainly showed diabeticketoacidosis (DKA) in the context of a new-onset diabetes with a pH of 7.22, partial pressure of carbon dioxide ( pCO 2 ) 12 mmHg, bicarbonates 5 mmol/L, random glucose 56.8 mmol/L, urinary ketones 7.8 mmol/L, sodium 158 mmol/L, chloride 111 mmol/L, potassium 7.9 mmol/L, urea 24.0 mmol/L, creatinine 302 µ mol/L, international normalized ratio (INR) 1.16, partial thromboplastin time 25.5 s, and fibrinogen 5.92 g/L. The calcu- lated osmolarity of 396.8 mOsm and intensity of the hyperglycemia evoked mixed features of hyperglycemic hyperosmolar state (HHS). A DKA protocol composed of intravenous insulin and normal saline fluid was started, and the latter rapidly changed to a quarter-normal saline and then dextrose 5% in water due to initial hypernatremia. Cerebral computed tomography scan showed no intracranial hemorrhage or other acute problems. No thromboprophylaxis was given. One of the two blood cultures returned positive for Gram-positive cocci in clusters 29.8 hours after admission for which vancomycin was started. Institutional Review Board approval as well as informed, written consent was not deemed necessary for the following retrospective review. All principles outlined in the Declaration of Helsinki were followed.
a life-threatening condition that occurs when metabolic acidosis, hyperglycemia, and ketonemia are simultaneously present in the patient. As glucose cannot be used as the primary fuel, fats (e.g. lipids) are broken down to acetoacetic and ß-hydroxylbutyric acids (ketones), which are naturally acidic, via lipolysis 171 . Excessive production of ketones (ketonemia) also acidifies the blood and overloads the bicarbonate buffering capacity causing ketoacidosis 200 . The lack of glucose uptake also switches muscles to anaerobic metabolism leading to the production of acidic lactate, further disrupting the acid-base homeostasis within the blood leading to metabolic acidosis 35 . The severity of the DKA episode is determined by the level of acidity in the blood, with mild DKA having a venous pH of 7.2-7.3, while moderate DKA has a pH of 7.1-7.2, and severe DKA has a pH of < 7.1 200 .