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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.