The diagnosis, treatment and impact of hyperosmolar hyperglycaemic hyperosmolar syndrome

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The diagnosis, treatment and impact of hyperosmolar hyperglycaemic hyperosmolar syndrome

Hyperosmolar hyperglycaemic syndrome (HHS) is an uncommon diabetic emergency that differs from diabetic ketoacidosis (DKA). The latter affects diabetic patients more frequently and, in common with HHS, leads to emergency hospital admission (Scott, 2015). HHS, however, has a higher mortality rate than DKA, of up to 58% (Scott, 2015), as opposed to 3-5% for DKA (Misra & Oliver, 2015). The causes of HHS, and why it develops instead of DKA, are not fully understood but risk factors include age, trauma, surgery and infection (Kitabchi et al., 2009).

The Joint British Diabetes Societies Inpatient Care Group (Scott, & Claydon, 2012) recommend that treatment for HHS focuses upon fluid replacement, which differs from insulin therapy, recommended for the treatment of DKA by the National Institute of Care Excellence (NICE, 2015). Currently, there are no NICE guidelines for the treatment of HHSnor is there a precise definition of HHS (Scott 2015). These knowledge deficits are a concern because, although HHS appears to largely affect older patients (and historically has been a rare occurrence), as rates of diabetes mellitus continue to increase across traditional age boundaries, HHS appears to be occurring at increasing frequency in young adults and children (Rosenbloom, 2010).

References:

Kitabchi, A.E., Umpierrez, G.E., Miles, J.M. and Fisher, J.N., 2009. Hyperglycemic crises in adult patients with diabetes. Diabetes care, 32(7), pp.1335-1343.

National Institute of Care Excellence (NICE), 2015. Type 1 diabetes in adults: diagnosis and management (NG17). [online] Available at https://www.nice.org.uk/guidance/ng17 Accessed 26 June 2017.

Misra, S. and Oliver, N.S., 2015. Diabetic ketoacidosis in adults. BMJ, 351 pp1-8. Also online: Available at: http://www.bmj.com/content/351/bmj.h5660 Accessed 25 June 2017.

Rosenbloom, A.L., 2010. Hyperglycemic hyperosmolar state: an emerging pediatric problem. The Journal of pediatrics, 156(2), pp.180-184.

Scott, A.R., 2015. Management of hyperosmolar hyperglycaemic state in adults with diabetes. Diabetic Medicine, 32(6), pp.714-724.

Scott, A., Claydon, A. (2012) The management of hyperosmolar hyperglycaemic state (HHS) in adults with diabetes. Joint British Diabetes Societies Inpatient Care Group [online] Available at: www.diabetes.nhs.co.uk Accessed 26 June 2017.

How effective are strategies to prevent diabetic foot ulcers?

Type 2 diabetes mellitus (T2DM) is a global health problem, affecting over 387 million people worldwide (International Diabetes Federation, 2014)). Diabetic patients have a 25% risk of developing a diabetic foot ulcer (DFU). Of these, one in six will need to have a limb amputated because the wound has become infected and/ or will not heal (Fortington et al., 2013). This outcome is associated with a 5-year mortality rate of 77%, higher than that for breast, colon and prostate cancers (Robbins et al., 2008).

Recently developed treatments are emerging to treat DBU’s, including bioengineered skin matrices, hyperbaric oxygen, low level light therapy and antimicrobial wound dressings (reviewed by Tchanque-Fossuo et al., 2015). This range of new, potentially effective treatments, poses challenges to clinicians and nurses treating patients with DBU’s; care must be supported by the best available evidence, yet also meet with patient concordance (Heisler et al., 2003). It is important that nurses have sufficient knowledge of the evidence underpinning the emerging options available in order to support patients in making informed decisions about their treatment, as demanded by the NMC (2015), and embodied by contemporary health policy such as ‘Liberating the NHS: No decision about me without me’ (Department of Health, 2012).

References:

Department of Health 2012. Liberating the NHS: No decision about me without me. [online] Available at: www.gov.uk Accessed 26 June 2017.

Fortington, L.V., Geertzen, J.H., van Netten, J.J., Postema, K., Rommers, G.M. and Dijkstra, P.U., 2013. Short and long term mortality rates after a lower limb amputation. European Journal of Vascular and Endovascular Surgery, 46(1), pp.124-131.

Heisler, M., Vijan, S., Anderson, R.M., Ubel, P.A., Bernstein, S.J. and Hofer, T.P., 2003. When do patients and their physicians agree on diabetes treatment goals and strategies, and what difference does it make?. Journal of General Internal Medicine, 18(11), pp.893-902.

International Diabetes Federation. 2014 Diabetes facts and figures. [online] Available at: http://www.idf.org/worlddiabetesday/toolkit/gp/facts-figuresAccessed 26 June 2017).

Nursing and Midwifery Council 2015. The Code: professional standards of practice and behaviour for nurses and midwives. [online] Available at: https://www.nmc.org.uk/standards/code/read-the-code-online/ Accessed 9 June 2017.

Robbins, J.M., Strauss, G., Aron, D., Long, J., Kuba, J. and Kaplan, Y., 2008. Mortality rates and diabetic foot ulcers: is it time to communicate mortality risk to patients with diabetic foot ulceration?. Journal of the American Podiatric Medical Association, 98(6), pp.489-493.

Tchanque‐Fossuo, C.N., Ho, D., Dahle, S.E., Koo, E., Li, C.S., Isseroff, R.R. and Jagdeo, J., 2016. A systematic review of low‐level light therapy for treatment of diabetic foot ulcer. Wound Repair and Regeneration, 24(2), pp.418-426.

What factors influence the efficacy of health promotion strategies designed to reduce the incidence of diabetes mellitus in (clients’ choice of country)?

Type 2 diabetes mellitus (T2DM) is a global public health problem, affecting over 387 million people (International Diabetes Federation, 2014). Efforts to reduce the incidence of T2DM have included health education, in which the importance of adopting a healthy lifestyle are emphasised (National Health Service (NHS) England, 2017; World Health Organization, 2016).

Several large randomised controlled trials have demonstrated that healthy lifestyle interventions have been successful in reducing the incidence of T2DM in populations at high risk by 29-58% (Tuomilehto et al., 2001; Pan et al., 1997). However, these trails have measured success in terms of effectiveness outcomes, within narrow range of health contexts, and have paid less attention to how lifestyle interventions supported by the data can be transferred to wider ranging settings, including primary care and schools (Tuomilehto et al., 2001).

To assist determining the most suitable evidence-based health promotion strategies that may be most effective for a specific patient or group, it is important to consider the factors that potentially influence the transferability of health promotion research. This could include socioeconomic and demographic differences, culture, health beliefs, education, access to health care and the availability of health promotion resources.

References:

International Diabetes Federation. 2014 Diabetes facts and figures. [online] Available at: http://www.idf.org/worlddiabetesday/toolkit/gp/facts-figuresAccessed 26 June 2017).

National Health Service (NHS) England, 2017. NHS England Diabetes Prevention Plan [online] Available at: https://www.england.nhs.uk/ourwork/qual-clin-lead/diabetes-prevention/ Accessed 10 June 2017

Pan, X.R., Li, G.W., Hu, Y.H., Wang, J.X., Yang, W.Y., An, Z.X., Hu, Z.X., Xiao, J.Z., Cao, H.B., Liu, P.A. and Jiang, X.G., 1997. Effects of diet and exercise in preventing NIDDM in people with impaired glucose tolerance: the Da Qing IGT and Diabetes Study. Diabetes care, 20(4), pp.537-544.

Tuomilehto, J., Lindström, J., Eriksson, J.G., Valle, T.T., Hämäläinen, H., Ilanne-Parikka, P., Keinänen-Kiukaanniemi, S., Laakso, M., Louheranta, A., Rastas, M. and Salminen, V., 2001. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. New England Journal of Medicine, 344(18), pp.1343-1350.

World Health Organization WHO 2016. Global report on diabetes [online] Available at: http://www.who.int/diabetes/global-report/en/ Accessed 26 June 2017.


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