What’s new
Patients with diabetes mellitus with a glucose level of ≥ 300 mg/dL
receive more treatment than patients with lower glucose levels.
Diagnosis and treatment at the right time in diabetes mellitus may be a
protective factor from renal disease.
INTRODUCTION
Diabetes mellitus (DM) is a metabolic disease characterized by
hyperglycemia caused by insulin release defects. 1There are different types of DM; it is divided into four classes. Type 1
DM (T1DM): absolute insulin deficiency develops due to pancreatic beta
cell damage. Type 2 DM (T2DM): progressive pancreatic beta cell damage
and an insulin release defect develop on the basis of insulin
resistance. Another type is due to genetic defects in beta cell or
insulin function, endocrinopathies, exocrine pancreatic diseases, and
drugs (drug-induced DM). Gestational DM (GDM): this is first diagnosed
during pregnancy. 2 The majority of individuals with
DM have T2DM and T1DM, T2DM being the most common. 3
According to the International Diabetes Federation (IDF) 7th Diabetes
Atlas, one in 11 people have been shown to have diabetes. Worldwide, the
number of patients with diabetes aged 20-79 years is around 60 million,
and this number is expected to reach 68 million by 2045.4 In addition, it is estimated that one in two people
with DM are undiagnosed and this corresponds to approximately 232
million people. 4 Therefore, preventive and emergency
physicians in particular should be more careful in diagnosing DM.
However, we think that DM is diagnosed late in our country, Turkey,
because people do not prefer primary healthcare services enough and do
not go to regular outpatient clinic checks. DM is a global health
problem with high treatment costs and is considered to be the epidemic
of the last century. 5 DM has inspired many studies
because it is an important disease in many respects such as its
complications, diagnosis, and financial burdens.
The diagnosis of DM is different according to the presence or absence of
symptoms in patients. Most patients are asymptomatic and hyperglycemia
is detected only in laboratory tests. The frequency of symptomatic
diabetes gradually decreases with the increased use of early diagnostic
tests. 6 In asymptomatic patients, some methods that
are accepted by the American Diabetes Association (ADA), European
Association for the Study of Diabetes (EASD) and IDF, are widely used in
the diagnosis of diabetes. DM was previously diagnosed through fasting
plasma glucose (FPG) and 2-hour 75 g oral glucose tolerance test (OGTT).
Then, in 2009, ADA, the IDF, and EASD suggested using glycated
hemoglobin (HbA1c) for diagnosis. 7 HbA1c ≥ 6.5% was
accepted as the threshold value for the diagnosis of DM. Diagnosing
efforts have brought various difficulties to the healthcare system, such
as loss of time for physicians and psychological stress in patients.
Various symptoms of hyperglycemia such as polyuria, polydipsia, dry
mouth, weight loss, and blurred vision are known. 6 In
the presence of these classic symptoms of hyperglycemia, it was decided
that no test repetition was required if the plasma glucose that was
randomly examined was ≥200 mg/dL. 8 This method will
make it easier for us to diagnose DM because it is not possible to
perform OGTT or to look for HbA1c in emergency departments as in
internal medicine or endocrinology outpatient clinics. Therefore, in our
study, we preferred serum glucose levels to be ≥200 mg/dL in symptomatic
patients as a diagnostic method.
Our aim was to investigate the frequency of DM in patients who were
admitted to the emergency department in whom high blood glucose levels
were detected, and to examine the subsequent treatment and follow-up of
these patients.
MATERIALS and METHODS
Ethics statement
This study was approved by the Ethics Committee of Kafkas University
Medical Faculty (Date: 29.05.2020 and number: 80576354-050-99/145).
Study design and the patients
Patients who were admitted to Kafkas University Research Hospital
emergency department between January 1st, 2019, and
December 31st, 2019, with symptoms of hyperglycemia
(dry mouth, frequent urination, abdominal pain, weakness, blurred
vision, fatigue and other additional symptoms) in whom serum glucose
levels were ≥200 mg/dL were retrospectively analyzed. All data about the
patients were obtained from the hospital registry system, the Ministry
of Health e-pulse application, and patient files.
Exclusion criteria were applied after excluding patients who had
previously been diagnosed as having diabetes (T1DM or T2DM).
Accordingly, patients aged under 18 years, pregnant women, patients who
used hormones or drugs to raise blood glucose levels, patients with
exocrine pancreatic diseases, endocrinopathies or active infection,
patients who were admitted due to major trauma, and patients with
missing files were not included in the study.
Patients’ age, sex, date of admission [month and hour
(00-06/06-12/12-18/18-00)], whether there was disease in their
history, blood parameter levels at the time of admission (hemoglobin,
leukocyte, platelet, glucose, sodium, potassium, chlorine, calcium,
urea, creatinine, blood gas) and ketone results in urine were
investigated.
We included a total of 140 patients with newly diagnosed T2DM. We
analyzed these patients under three groups: patients who had not been to
an outpatient clinic for treatment (group 1), patients in whom drug
treatment was started (group 2), patients in whom drug treatment was not
started (group 3). When we examined the patients (n =86) who were
admitted to the outpatient clinic for diagnosis and treatment, we found
that the number of patients with glucose levels between 200-300 mg/dL
was higher. We divided these patients into two groups: Patients with
serum glucose level ≥300 mg/dL and <300 mg/dL.
Statistical analysis
Statistical analysis was mainly performed using the Predictive Analysis
Soft Ware (PASW) program (version 18.0; SPSS™, Chicago, IL). Data for
quantitative variables were defined as mean ± standard error (SEM). Data
on categorical variables were defined as numbers and / or percentages.
If the continuous variables did not have normal distribution, they were
evaluated using the Shapiro-Wilk test. All tests were two tailed and
p<0.05 was considered significant. The Chi-square test or
Fisher’s exact test was used to compare categorical variables. The
Kruskal-Wallis test was used in triple-group comparisons because the
groups met nonparametric assumptions. In cases where a difference was
observed, the Bonferroni-corrected Mann-Whitney U test was used to
understand from which group this difference originated. In group
comparisons, Bonferroni correction was used to avoid estimated type 1
errors and p values <0.017 were considered statistically
significant
RESULTS
When the patients who were admitted to the emergency department were
scanned in the last year, the total number of patients with serum
glucose levels ≥200 mg/dL was 838. Of these, 616 patients who were
previously diagnosed as having DM were excluded from the study. The
remaining 222 patients did not know that they had DM. A total of 140
patients were included in the study after patients who met our exclusion
criteria were excluded (Figure 1).
No patients were diagnosed as having T1DM, only one patient was
diagnosed as having GDM and this patient was excluded (Figure
1).
The mean age of the patients was 64.77 ± 15.88 years. Seventy-three
(52.1%) were men and 67 (47.9%) were women. Group 1 comprised patients
whom had never attended any internal medicine or endocrinology
outpatient clinics for DM (n=54, 38.57%). When the outpatient clinic
records of the remaining 86 patients were examined for DM treatment, it
was determined that medication was not started in 50 patients (35.71%)
(group 2), and that medication was started in 36 patients (25.71%)
(group 3.) The male and female ratios of groups 1, 2, and 3 were close
to each other (Table 1).
When the mean ages of all three groups were compared, a significant
difference was detected (p<0.05). The mean age of group 1 was
significantly higher than in group 2 and group 3 according to the
Bonferroni-corrected Mann-Whitney U test. The mean ages of group 1, 2,
and 3 were 69.6 ± 13.6 years, 61.1 ± 14.9 years, and 60.9 ± 17 years,
p<0.017, respectively) (Table 1).
No statistically significant relationship was found between patients’
sex, glucose levels, and other blood parameters (p>0.05).
When the patients were examined according to their admission months, it
was seen that the highest number of admissions (n=18, 12.9%) was in
March. When the admission hours were examined, an increase was observed
in the frequency of admissions in the afternoon and evening hours.
However, when the admission months and hours were examined, there was no
statistically significant relationship between the groups
(p>0.05) (Data not shown).
When the medical histories of the patients were scanned, it was found
that cardiovascular, respiratory, neurologic, psychiatric, digestive,
endocrine, and renal system diseases were most frequent. When the groups
with and without medication were compared in terms of additional
diseases, no difference was found between the two groups in terms of
non-renal diseases. There were significantly fewer patients with renal
disease in the group in which medication was initiated than in the group
for which medication was not initiated (p=0.019) (Table 2).
Patients who were admitted to outpatient clinics for treatment were
compared in terms of serum glucose levels. Patients with glucose levels
≥300 mg/dL were significantly more likely to be on medication than those
with glucose levels <300 mg/dL (p=0.031). Again, the 95%
confidence interval (CI) value of the group with glucose levels ≥300
mg/dL was found as 1.08-7.76 (Table 3).
DISCUSSION
This study is the first and only pilot study on the incidental diagnosis
of DM in emergency departments in Turkey. Although the priority of
emergency departments is not to diagnose chronic diseases, they have an
important role in the detection of DM. In studies conducted on the sex
distribution of DM, it was observed that the distribution of women and
men was very similar. 9,10 Sharma et al. found that
the frequency of diabetes in both sexes increased in poor regions as the
age progressed. Similarly, in our study, the male and female ratio was
similar. 11
The mean ages of the patients with DM were found as 61.0 ± 12.1, 62.1 ±
9.7, 65 ± 19, and 62.7 ± 19.4 years in the studies by Akaltun et
al,12 Ludovico et al,13 Iglay et
al,14 and Layton et al,15respectively. Our study was compatible with the literature; we thought
that our study performed in a region with low economic income and that
the comorbid diseases increasing with age increased the incidence of DM
in our study.
On the other hand, several studies have been conducted examining the
relationship between DM frequency and seasonal change. In a study by
Katsarou et al,16 it was found that the blood glucose
levels were the lowest in winter and the highest in summer. In the study
where Bando et al., investigated the relation between seasonal
variability and HbA1c in Japan, it was found that HbA1c increased in the
summer months and decreased in the autumn months. 17In another study, the seasonal changes and the length of the seasons
were thought to be effective on the frequency of DM. Unlike the
literature, the long period of winter in the Kars province caused
approximately 40% of our patients to be detected in this season. We
believed that the high number of patients in the winter months compared
with other months was due to the effects of decreased physical activity,
nutritional culture, consumption of foods rich in carbohydrates, and
less exposure to sun rays on endocrine metabolism.
When studies investigating the hours of admission to the emergency
department were examined, it was found that 46% of patients were
admitted between 08:00 and 17:00 in the study by Emet et al,18. In the study conducted by Köse et al,19 it was found that the admissions between
08:00-17:00 constituted 60.5% of the total admissions. There is no
study on admission hours of patients with newly diagnosed DM to the
emergency department; our study is the first in this regard. Although
newly diagnosed DM was more common between 18:01-00:00 compared with
other hours, it was noteworthy that the admissions between 12:01-00:00
constituted 67.9% of all admissions.
GDM is the glucose intolerance that occurs for the first time during
pregnancy. GDM can be seen in approximately 7% of all pregnancies.20 It is not possible to diagnose GDM in emergency
departments because GDM is diagnosed with OGTT. In our study, a patient
was diagnosed as having GDM after being referred to an outpatient
clinic. The number of patients with DM related to pregnancy was low in
our study because pregnant women preferred outpatient clinics rather
than emergency departments.
On the other hand, the presence of hyperglycemia may affect serum
electrolyte concentrations in patients. These individuals may experience
electrolyte disturbances due to osmotic variations, drugs used,
acid-base imbalances, and renal dysfunction. 21 A
negative correlation between serum glucose and serum sodium levels was
detected, but there was no correlation between other parameters in a
study on the relation between diabetes and electrolyte levels.10 In our study, no significant relationship was found
between glucose levels and electrolyte levels. We think that there is a
need for more extensive research on this subject.
We observed that 38.5% of the patients that we sent to the outpatient
clinic with a suspicion of DM did not make an outpatient admission. We
thought that the most important reason for this situation was low health
literacy, which includes planning lifestyle in chronic diseases, making
informed decisions, and knowing when and how to access health services.22 Studies have reported that health literacy is low
among patients with diabetes. 23,24
Late diagnosis and late starting of treatment creates irreversible
complications as well as increased treatment costs and economic burdens.
Studies on the increase in the economic burden caused by diabetes seem
to be most prominent. Zhuo et al, 25 stated that the
cost of lifelong medical treatment after a patient is diagnosed as
having DM at the age of 50 would be $135,000.
A study was conducted on patients who were admitted to the emergency
department with random finger-stick blood glucose value above 126 mg/dL.
It was observed that 41% of the patients had a history of DM.26 In our study, this rate was 26.49% among patients
with a serum glucose level above 200 mg/dL. For the first time, we
determined the frequency of incidentally diagnosed DM in the emergency
department as 16.70%. It has become necessary to diagnose DM in
emergency departments because diabetes is a serious health problem both
for a country’s economy and for patients.