Problem In Diabetic Patients Research Articles

High frequency of carbapenem-resistant Acinetobacter baumannii in patients with diabetes mellitus in Saudi Arabia

Carbapenem-resistant Acinetobacter baumannii is becoming increasingly prevalent in patients with diabetes mellitus in the Middle East. We examined the relationship of these bacteria and their resistance mechanisms to the diabetic disease status of patients in Saudi Arabia. Susceptibilities of 271 isolates to carbapenems, tigecycline and colistin were determined, followed by detection of carbapenemase genes. A blaVIM gene was detected in ~95 % of isolates; blaOXA-23 and blaOXA-40 genes were also prevalent. Diabetic patients were significantly more likely to carry carbapenem-resistant isolates. Carbapenem-resistant A. baumannii is a serious problem in diabetic patients, and molecular detection of resistance mechanisms in these isolates is required.

Cardiometabolic Diseases and Related Complications: Current Status and Future Perspective

Cardiometabolic Diseases and Related Complications: Current Status and Future Perspective

MECHANISMS IN ENDOCRINOLOGY: Seizures and type 1 diabetes mellitus: current state of knowledge

In this review, we will try to analyze the possible coexistence between epilepsy or seizures and type 1 diabetes mellitus (T1DM), in order to establish if there is more than a casual association, and to investigate possible mechanisms underlying this link. Anti-glutamic acid decarboxylase antibodies (GAD-Abs) have been associated with T1DM and a great number of neurological diseases such as epilepsy. Epilepsy can be a feature of a large variety of autoimmune or inflammatory disorders. GAD-Abs can have a role at the basis of the possible link between epilepsy and T1DM, although their real pathogenetic mechanism in neurological diseases is still unknown. Metabolic conditions such as hypoglycemia and hyperglycemia, common problems in diabetic patients, may be also implicated, even if their underlying mechanism is minimally understood.

Low back pain in diabetes mellitus and importance of preventive approach.

Musculoskeletal pain is known to be a common problem in diabetic patients. In spite of this fact, there is little information about epidemiology aspect of Low Back Pain (LBP) and necessity of taking preventive approach in diabetic patients. The aim of this study was to determine the prevalence of LBP in diabetic patients and its comparison with non-diabetic subjects. Low back pain frequency was examined among 317 diabetic patients referred to endocrine clinic, Sina Hospital, Tabriz city, Iran during 3 months interval. The control group included 100 participants who were parents of students of Tabriz University. All participants were asked to fill out a questionnaire including Roland Morris Disability Questionnaire (RMDQ) and Face Pain Scale (FPS). Of the 317 diabetic patients, 63.4% (201) reported LBP while in non-diabetic group was 47% (47).The average functional disability in diabetic group was 9 while in control group was 7. Inter-correlation between low back pain intensity scale and functional disability were significant (r=0.52, P<0.01). Low back pain is a common problem in diabetic patients in terms of intensity, frequency and functional level of disability.

Why Critical Limb Ischemia Criteria are Not Applicable to Diabetic Foot and What the Consequences are

Neuropathy, peripheral arterial occlusive disease and microvascular disturbances are important factors contributing to foot problems in diabetic patients. In the diabetic foot with ischemia, the alterations in skin microvascular function are pronounced including severely reduced capillary circulation and abolished hyperaemic responses. These microvascular disturbances, which are superimposed on the already existing structural diabetic microangiopathy, are compatible with a state of "chronic capillary ischemia" and an increased shunting of blood through arteriovenous channels. This maldistribution of blood in skin microcirculation is not detected by measurement of peripheral blood pressure (systolic ankle blood pressure, systolic toe blood pressure). As indicated in several studies toe blood pressure is a poor predictor of local tissue perfusion, tissue survival and healing of chronic foot ulcers. Consequently, the disturbances in peripheral tissue perfusion of the diabetic foot may be underestimated leading to delayed vascular interventions and/or medical treatment. Thus, measurements of peripheral blood pressure, e.g. toe blood pressure, should be combined with investigations of local tissue perfusion in order to get an adequate estimation of peripheral tissue perfusion in diabetic patients. For this purpose local skin microcirculation can be investigated by transcutaneous oxygen tension of the forefoot. Also, due to these reasons, the threshold for revascularization should be lower in diabetic patients with foot ulcer.

Topical Application of Sadat-Habdan Mesenchymal Stimulating Peptide (SHMSP) Accelerates Wound Healing in Diabetic Rabbits

Objective. Diminished wound healing is a common problem in diabetic patients due to diminished angiogenesis. SHMSP was found to promote angiogenesis. The present study was carried out to examine the effect of this peptide in healing of wounds in diabetic rabbits. Materials and Methods. Twenty male New Zealand rabbits were used in this study. Diabetes mellitus was induced and the rabbits were randomly divided into two equal groups: control group and peptide group. A-full thickness punch biopsy was made to create a wound of about 10 mm on the right ears of all rabbits. Every day, the wound was cleaned with saline in control groups. In the peptide group, 15 mg of SHMSP was applied after cleaning. On day 15th, all animals were sacrificed, and the wounds were excised with a rim of 5 mm of normal surrounding tissue. Histo-pathological assessment of wound healing, inflammatory cell infiltration, blood vessel proliferation, and collagen deposition was performed. Results. There were no deaths among the groups. There was significant increase in wound healing, blood vessel proliferation and collagen deposition, and significant decrease in inflammatory cell infiltration in the peptide group compared to the control group. Conclusion. Topical application of SHMSP improves wound healing in diabetic rabbits.

Effects of metformin on spontaneous and cholinergic contractions of the rat bladder

Diabetes causes autonomic neuropathy which impairs bladder parasympathetic release of acetylcholine (ACh) during the active phase of micturation, resulting in inadequate voiding of urine. Diabetes also causes incontinence which is a problem during storage of urine in the resting bladder. Previously we reported that a high (10 millimolar) concentration of the antidiabetic drug metformin can rapidly enhance rat bladder contractile responses to ACh (FASEB J. 22:916.6, 2008).We tested whether long‐term (4‐hour) pretreatment with a lower, more therapeutically‐relevant concentration of metformin (100 micromolar) would do the same. First, after 4 hours the 100 micromolar metformin exerted contrasting effects on cholinergic (ACh‐induced) vs non‐cholinergic (e.g. K‐induced) contractions of isolated rat bladder tissues (p &lt; 0.05), tending to enhance the former (by 31–51%) and inhibit the latter (by 9–18%). Second, during the pretreatment period the 100 micromolar metformin interacted with pretreatment time (p &lt; 0.05) to specifically increase amplitudes of resting spontaneous contractile activity (after 2–4 hours) without altering the midpoint level of resting contractile tone or the frequency of the spontaneous activity. These findings may be relevant to potential effects of metformin on the abovementioned clinical problems in diabetic patients. Support: Midwestern University.

Enhanced Healing of Diabetic Wounds by Topical Administration of Adipose Tissue-Derived Stromal Cells Overexpressing Stromal-Derived Factor-1: Biodistribution and Engraftment Analysis by Bioluminescent Imaging

Chronic ulcers represent a major health problem in diabetic patients resulting in pain and discomfort. Conventional therapy does not guarantee adequate wound repair. In diabetes, impaired healing is partly due to poor endothelial progenitor cells mobilisation and homing, with altered levels of the chemokine stromal-derived factor-1 (SDF-1) at the wound site. Adipose tissue-associated stromal cells (AT-SCs) can provide an accessible source of progenitor cells secreting proangiogenic factors and differentiating into endothelial-like cells. We demonstrated that topical administration of AT-SCs genetically modified ex vivo to overexpress SDF-1, promotes wound healing into diabetic mice. In particular, by in vivo bioluminescent imaging analysis, we monitored biodistribution and survival after transplantation of luciferase-expressing cells. In conclusion, this study indicates the therapeutic potential of AT-SCs administration in wound healing, through cell differentiation, enhanced cellular recruitment at the wound site, and paracrine effects associated with local growth-factors production.

Evaluation of the weight‐increasing effects of biphasic analog and regular NPH insulin mixtures in patients with Type 2 diabetes mellitus

Weight gain is a significant problem in diabetic patients in terms of worsening glycemic control, increasing diabetic and cardiovascular morbidity and mortality, and contributing to social and psychological problems. In the present study, we evaluated the effects of a biphasic analog and regular NPH insulin mixtures on weight gain in patients with Type 2 diabetes mellitus (T2DM) over 1 year. Group I consisted of 71 patients (29 men and 42 women) being treated with analog mixtures (insulin lispro 75/25 mix and biphasic insulin aspart 70/30 mix) twice daily; Group II consisted of 69 patients (23 men and 46 women) being treated with a regular insulin mixture (70/30) twice daily. Starting weight, body mass index, HbA1c, and hypoglycemic episodes were evaluated after 6 and 12 months. Weight gain in Group I at 6 and 12 months was 1.41 ± 2.70 and 2.08 ± 3.74 kg, respectively. In Group II, weight gain at 6 and 12 months was 1.5 ± 3.0 and 2.29 ± 3.85 kg, respectively. Intragroup comparisons indicated that, for both groups, weight gain at 6 and 12 months differed significantly from the starting weight. However, no significant differences in weight gain were found between the two groups (P > 0.05). The weight-increasing effects of an analog mixture of insulin and the NPH regular mixture of insulin appear to be similar. This should be taken into account when determining the type of insulin to use in treating T2DM patients.

Outcome of foot examinations in Tanzanian and Swedish diabetic patients, a comparative study

The aim of the current study was to present the outcome of clinical nurse performed foot examinations in a group of Tanzanian diabetic patients and make comparisons with matched Swedish patients. Nurses working with diabetic patients in any country need to be familiar with foot problems in diabetic patients to educate patients about foot care. A comparative study examining diabetic patients in Tanzania and Sweden with a quantitative approach. One hundred and forty-five diabetic patients in each country were examined. They were matched in gender and age. All patients responded verbally to questions about individual foot-care and underwent clinical foot examination concerning existing foot lesions, sensitivity testing using Semmes-Weinstein monofilament (5.07) and, vibratory perception using a tuning fork (128 Hz). The Tanzanians had more reported foot problems than the Swedes. The latter reported problems due to poorly fitting footwear whilst the Tanzanians reported pain issues of the feet irrespective of footwear. In the Tanzanian group 37 patients presented with peripheral neuropathy (PN), 13 with peripheral vascular disease (PVD) and six had both PN and PVD. In the Swedish group of patients four had PN, three PVD, but none had both PN and PVD. Only 20 Tanzanians reported carrying out self-inspections of their feet, while 103 Swedes reported doing so. Nurse performed foot examinations showed that the Tanzanian diabetic patients in this study had poorer foot status than the Swedish study sample. Knowledge about foot problems in diabetic patients worldwide will hopefully improve education about self foot-care and therefore decrease incidence of foot lesions and other foot problems in this cohort.

Group of Signs: A New Method to Evaluate Glycemic Variability

Glycemic variability is an important parameter used to resolve potential clinical problems in diabetic patients. It is known that glycemic variability generates oxidative stress and potentially contributes to the development of macro- and microvascular complications in diabetes. By controlling glycemic variability, it is possible to reduce these complications and to set the therapy for all patients with diabetes. The aims of this study were to (1) propose a new standardized, objective, and flexible approach to measure glycemic variability by a continuous glucose monitoring system (CGMS)-the group of signs (GOS) method; (2) compare the correlation between mean amplitude of glucose excursion (MAGE), a well-known index of glycemic variability calculated by the physician and the MAGE defined with the GOS method, in order to validate the GOS; and (3) suggest new indexes of glycemic variability. We tested the GOS algorithm on data collected by a CGMS every 5 minutes for 24 hours on 50 patients. Consequently, for 8 patients we calculated and compared the physician's MAGE in the standard way and by the GOS method. Comparison between the two methods has shown high correlations, from a minimum correlation of 86% to a maximum of 98%, with p values <0.01 (Pearson test). Preliminary data suggest that the proposed algorithm is a valid, efficient, and reliable method able to calculate the standard MAGE on CGMS data systematically and to create other alternative glycemic variability indexes.

Effect of a single bout of moderate exercise on glucose uptake in type 2 diabetes mellitus

Hypoglycemia during exercise is a serious problem in diabetic patients during cardiac rehabilitation, whereas normal subjects rarely experience hypoglycemia. Inappropriate glucose uptake by working muscles may be responsible. However, the precise characteristics of glucose uptake during exercise have not been fully studied. We have investigated the effect of acute exercise on glucose uptake in diabetic patients. Nine type 2 diabetic patients (age, 57 ± 6 years; HbA1c, 7.7 ± 1.3%) performed exercise at an intensity of anaerobic threshold for 15 min. Glucose utility was determined using euglycemic hyperinsulinemic clamp technique. Glucose infusion rate (GIR) was calculated throughout the exercise and recovery session. Average GIR at rest was 3.4 ± 1.6 mg/(kg(BW)min). Fifteen minutes after starting exercise, it increased significantly (6.6 ± 2.4, p < 0.001). Thirty minutes after cessation of exercise, GIR decreased significantly (4.8 ± 1.9, p < 0.05) compared with peak value. Increase in GIR was greater as BMI or body fat ratio became greater (r=0.608 and 0.475). There was a weak correlation (r=0.344) between HbA1c and GIR improving ratio (GIR during exercise x 100/GIR at rest). Glucose uptake was revealed to augment significantly within 15 min after the commencement of exercise. This improvement was more obvious in patients with greater body weight, fat accumulation, and poorer diabetic control.

In vitro and in vivo wound healing-promoting activities of β-lapachone

Impaired wound healing is a serious problem for diabetic patients. Wound healing is a complex process that requires the cooperation of many cell types, including keratinocytes, fibroblasts, endothelial cells, and macrophages. beta-Lapachone, a natural compound extracted from the bark of the lapacho tree (Tabebuia avellanedae), is well known for its antitumor, antiinflammatory, and antineoplastic effects at different concentrations and conditions, but its effects on wound healing have not been studied. The purpose of the present study was to investigate the effects of beta-lapachone on wound healing and its underlying mechanism. In the present study, we demonstrated that a low dose of beta-lapachone enhanced the proliferation in several cells, facilitated the migration of mouse 3T3 fibroblasts and human endothelial EAhy926 cells through different MAPK signaling pathways, and accelerated scrape-wound healing in vitro. Application of ointment with or without beta-lapachone to a punched wound in normal and diabetic (db/db) mice showed that the healing process was faster in beta-lapachone-treated animals than in those treated with vehicle only. In addition, beta-lapachone induced macrophages to release VEGF and EGF, which are beneficial for growth of many cells. Our results showed that beta-lapachone can increase cell proliferation, including keratinocytes, fibroblasts, and endothelial cells, and migration of fibroblasts and endothelial cells and thus accelerate wound healing. Therefore, we suggest that beta-lapachone may have potential for therapeutic use for wound healing.

Frequency, Risk Factors, and Responsible Pathogenic Microorganisms of Asymptomatic Bacteriuria in Patients with Type 2 Diabetes Mellitus

Urinary tract infection is a serious problem in diabetic patients, and asymptomatic bacteriuria (ASB) in these patients is a risk factor for pyelonephritis and renal dysfunction. In the present study, we investigated the relationships between age, body mass index, duration of diabetes, HbA1c level, glucosuria, glomerular filtration rate and microalbuminuria in type 2 diabetic patients with ASB. One hundred and twenty-three patients with type 2 diabetes mellitus were included in the study. The patients were divided into two groups according to ASB; Group I consisted of 22 patients with ASB, and Group II of 101 patients without ASB. There were no significant differences between the groups in regard to age, body mass index, creatinine clearance or microalbuminuria, while there were significant differences in HbA1c, duration of diabetes mellitus, glucosuria and pyuria (P < 0.05). The most commonly isolated microorganism was Escherichia coli. The present study identified the duration of diabetes, high HbA1c, glucosuria and pyuria as risk factors for ASB in type 2 diabetic patients.

Assessment and treatment of diabetic foot ulcer

Foot ulcers are one of the main complications in diabetes mellitus, with a 15% lifetime risk in all diabetic patients. The rate of lower extremity amputation among diabetic patients is 17-40 times higher than in non-diabetics. A critical triad of neuropathy, minor foot trauma and foot deformity was found in > 63% of diabetic foot ulcers (DFU). Peripheral vascular disease (PVD) has been identified in 30% of foot ulcers. We present a comprehensive assessment and the treatment of DFUs. We also want to notify physicians not to ignore foot assessment and examinations in patients with diabetes. We conducted this study on DFU on the basis of: pathogenesis and risk factors, assessment and physical examination, paraclinic assessment, treatment, cost and mortality and prevention. Approximately 20% of hospital admissions among diabetic patients are the result of foot problems. Diabetic foot assessment should include dermatological, vascular, neurological and musculoskeletal systems. There are three basic treatments for management of DFU: (i) debridement; (ii) antibiotics and (iii) revascularization. The cost to treat one simple ulcer is $5000 to $8000. Awareness of physicians about foot problems in diabetic patients, clinical examination and paraclinical assessment, regular foot examination, patient education, simple hygienic practices and provision of appropriate footwear combined with prompt treatment of minor injuries can decrease ulcer occurrence by 50%.

Ethanol Acutely Stimulates Islet Blood Flow, Amplifies Insulin Secretion, and Induces Hypoglycemia via Nitric Oxide and Vagally Mediated Mechanisms

Hypoglycemia induced by alcohol ingestion is a well-known problem in diabetic patients. However, the mechanisms underlying this phenomenon have largely remained elusive. Because insulin secretion in vivo can be rapidly tuned by changes in pancreatic microcirculation, we evaluated the influence of acute alcohol administration on pancreatic islet blood flow (IBF), and dynamic changes in insulin secretion and glycemia in the rat. Ethanol (10%) or saline was iv injected as a bolus into Wistar rats, yielding serum ethanol concentrations of approximately 8 mmol/liter. Measurements of pancreatic blood flow (PBF) were performed by a microsphere technique in combination with a freeze-thawing technique after 10-min injection. Ethanol preferentially and significantly increased pancreatic IBF approximately 4-fold, whereas not influencing whole PBF. The alcohol also augmented late-phase insulin secretion and induced late hypoglycemia upon ip glucose tolerance tests. The nitric oxide synthase inhibitor N-w-nitro-L-arginine methyl ester and atropine prevented the increased pancreatic IBF, enhanced insulin secretion, and hypoglycemia evoked by ethanol. Thus, our findings demonstrate that ethanol acutely exerts substantial influences on pancreatic microcirculation by evoking a massive redistribution of PBF from the exocrine into the endocrine part via mechanisms mediated by nitric oxide and vagal stimuli, augmenting late-phase insulin secretion, and thereby evoking hypoglycemia. This effect may in part underlie the well-known hypoglycemic properties of alcohol in diabetic patients or in alcoholics with hepatic failure.

A therapeutic approach for diabetic wound healing using biotinylated GHK incorporated collagen matrices

Chronically elevated blood glucose levels result in reduced leukocyte function and cell malnutrition, which contribute to a high rate of wound infection and associated healing problems in diabetic patients. In the present study, the role of biotinylated GHK peptide (BioGHK) incorporated collagen biomaterial was tested for wound healing in diabetic rats. The rate of wound contraction and the levels of collagen, uronic acid, protein and DNA in the granulation tissue were determined. Further, the concentration of nitric oxide and other skin antioxidants was also monitored during the study. In diabetic rats treated with BioGHK incorporated collagen (Peptide Incorporated Collagen — PIC), the healing process was hastened with an increased rate of wound contraction. Glutathione (GSH) and ascorbic acid levels in the skin of streptozotocin-induced diabetic rats were higher in the PIC group as compared to control (Untreated) and collagen (Collagen Film — CF) treated groups. Superoxide dismutase (SOD) and catalase (CAT) activity was altered in all the groups. In vitro fibroblast cell culture studies suggest that PIC promotes fibroblast growth. Histological evaluation by haematoxylin–eosin and Masson's trichrome method revealed epithelialization, increased synthesis of collagen and activation of fibroblasts and mast cells in the PIC group. This study provides a rationale for the topical application of BioGHK incorporated collagen as a feasible and productive approach to support diabetic wound healing.

Successful treatment of diabetic foot ulcers with low-level laser therapy

Introduction Diabetic foot ulcers, being notoriously difficult to cure, are one of the most common health problems in diabetic patients. There are several surgical and medical options already introduced for treatment of diabetic foot ulcers. Low-level laser therapy (LLLT) has been suggested as a promising treatment option for open wounds. However, there is very little work on the efficacy of low-level laser therapy for this type of open wounds. We report herein seven cases of grades II and III diabetic foot ulcer completely treated with LLLT. Materials and methods Seven Type 2 diabetic patients (four males: mean age, 63 years; three females: mean age, 61.14 years) with grades II and III diabetic foot ulcers were treated with low-level laser therapy. The mean duration of diabetes was 10.5 years and the ulcers were present from average 6.5 months ago. The mean value for glycosylated hemoglobin (HbA1C) also was 8.14 mg/dl (range: 6–12.2) and foot blood flow in Doppler ultra-sonography were normal. We used low-level laser therapy through local irradiation of the ulcer bed with red light (660 nm; power: 25 MW; 0.6–1 J/cm 2) and ulcer margins with infrared laser (980 nm; power: 200 MW; 4–6 J/cm 2), along with intravenous laser irradiation with red light laser (650 nm; power: 1.5 MW) for 15–20 min, in addition to laser acupuncture with infrared laser (1 J/cm 2) for LI-11, LI-6, SP-6, PC-6, ST-36 and GB-34 points. Sessions were every other day for 10–15 sessions (Route 1) and then continuing the course twice weekly (Route 2) until complete recovery was achieved. Results After approximately 19 sessions (mean Route 1 sessions ≈15; mean Route 2 sessions ≈10), complete recovery was achieved in all cases and there was no relapse or other problem with ulcers after approximately 6 months (range: 2–10 months) of follow-up. With this treatment regimen, there were no side-effects reported by the patients. Conclusion Low-level laser therapy could be a safe and effective method for treatment of diabetic foot ulcers. Clinical trials with higher sample size are proposed to more evaluate the efficacy of low-level laser therapy in treatment of this type of wounds.

Peritoneal Dialysis Prescription for Diabetic Patients

The number of end-stage renal disease (ESRD) patients with diabetes mellitus has increased dramatically during the past few years and, in many countries, diabetes has become the most important cause of ESRD in patients admitted to dialysis. Furthermore, compared to nondiabetic patients, diabetic patients continue to suffer from more frequent and severe comorbidity and complications, including cardiovascular disease, poor fluid balance, worse quality of life, as well as high morbidity and mortality after initiation of dialysis. These systemic problems in diabetic patients should influence the dialysis prescription. In addition, the structure and transport properties of the peritoneal membrane may deteriorate as a consequence of diabetes. Thus, both the systemic and the peritoneal consequences of diabetes influence the dialysis prescription in diabetic patients. In this brief review, we discuss the care of diabetic ESRD patients on peritoneal dialysis--which, compared with hemodialysis, has both advantages and disadvantages in this group of patients--focusing on the special needs for intense and integrated care involving individualized dialysis prescription as well as care of diabetic complications and comorbidity in this diseased patient group.

Point of Care Blood Ketone Testing of Diabetic Patients in the Emergency Department

The aim of our study was to determine the utility of point‐of‐care blood ketone testing in diabetic patients presenting to the emergency department. In this prospective, observational clinical study, patients with known or newly diagnosed diabetes mellitus presenting to our tertiary care university emergency department with any nontrauma related medical complaint and a high fingerstick glucose (≥ 200 mg/dL) were eligible for inclusion. Capillary blood β‐hydroxybutyrate (β‐HBA), venous blood β‐HBA level, venous blood glucose level, arterial blood gas analysis, and urine ketone dipstickstick were measured in each patient as primary outcome measures. Of the 479 diabetic patients presenting during the study period, a total of 139 diabetic patients with high capillary blood glucose level (≥ 200 mg/dL) and a positive capillary blood β‐HBA (≥ 0.1 mmol/L) were included in the study. Hyperketonemia (≥ 0.42 mmol/L) was found in 48 of these patients by Sigma Diagnostics reference testing (diabetic ketosis in 35%). The calculated blood pH was less than 7.3 in 18 of these 48 patients (ketoacidosis in 31%). Capillary and venous blood β‐hydroxybutyrate levels were not statistically different from each other (P = 0.824). There was a positive correlation between capillary and venous blood β‐HBA levels (r = 0.488, P < 0.001). The sensitivity and specificity of urine ketone dipstick testing and capillary blood ketone testing in determining diabetic ketoacidosis were 66% and 78%, and 72% and 82%; and in determining hyperketonemia (both in diabetic ketosis and diabetic ketoacidosis) were 82% and 54%, and 91% and 56%, respectively. A rapid, bedside capillary blood ketone test for β‐HBA can accurately measure blood concentrations of β‐HBA in diabetic patients in an emergency department setting. This device can be used as a reliable diagnostic test to detect emergency metabolic problems in diabetic patients, such as diabetic ketosis or ketoacidosis.