Acute Complications Of Diabetes Research Articles

1010-P: Prevalence of Acute Diabetes Complications following Cancer Diagnosis and Treatment

Introduction: Multiple case studies have reported diabetic ketoacidosis (DKA) in recently-diagnosed cancer patients, especially those taking immune checkpoint inhibitors. The prevalence of DKA and other acute diabetes complications (ADC), including hypoglycemia and hyperosmolarity, and their relationship with the onset of systemic cancer therapy is unclear. Methods: This study utilized data from n=9,588 cancer patients from the Huntsman Cancer Institute, UT. Data on clinicodemographic characteristics, biomarkers, and cancer diagnoses were extracted from electronic medical records (EMR) and tumor registry. Patients included in this analysis received an ICD diagnosis of hypoglycemia, hyperosmolarity with or without coma, and/or DKA with or without coma. Systemic therapy was defined as any chemotherapy, immunotherapy or hormone therapy resulting from a specific first primary cancer diagnosis. Results: There were 243 instances of ADC within this cohort, occurring in 211 (2.2%) unique patients. Of these 211 unique patients with an ADC, 106 (50.0%) experienced their first ADC within one year after cancer diagnosis, with a median time to ADC diagnosis of 88 days. Forty-seven (44%) of these patients experienced the ADC following the onset of systemic therapy, with a median time from systemic therapy onset to ADC diagnosis of 120 days. In these 47 patients who received an ADC diagnosis following the onset of systemic therapy, 40 (85.1%) received chemotherapy (n=20 as monotherapy), 20 (42.6%) received immunotherapy (n=4 as monotherapy) and 12 (25.5%) received hormone therapy (n=2 as monotherapy). Only 54% of patients experiencing an ADC after cancer diagnosis had a history of diabetes prior to cancer, and on average their first diabetes diagnosis was 5.4 ± 4.4 years prior to their cancer diagnosis. Discussion: ADCs may be common following a cancer diagnosis, however a substantial number occurred prior to the onset of systemic cancer therapy and in patients with no prior history of diabetes. Disclosure R. Viskochil: None. S. Hardikar: None. S. Pauleck: None. M. Winn: None. K. Funai: None. M. L. Litchman: Research Support; Self; Abbott Diabetes. W. Akerley: None. H. Colman: Advisory Panel; Self; Adastra Pharmaceuticals, Orbus Therapeutics, Consultant; Self; Best Doctors/Teladoc. C. M. Ulrich: None. M. C. Playdon: None. Funding University of Utah Health/Larry H. Miller Family Wellness Initiative

The Efficacy and Safety of Chinese Medicine Fufang Zhenzhu Tiaozhi Capsule (FTZ) in the Treatment of Diabetic Coronary Heart Disease: Study Protocol for Multicenter, Randomized, Double-Blind, Placebo-Controlled Clinical Trial.

BackgroundDiabetic coronary heart disease (DCHD), the main macrovascular complication of type 2 diabetes mellitus (T2DM), is greatly harmful to T2DM patients. Traditional Chinese medicine (TCM) is an alternative and effective therapy to delay the development of macrovascular diseases, but the existing evidence of its efficacy and safety is insufficient. The aim of this multicenter, randomized, double-blind, placebo-controlled trial is to evaluate the efficacy and safety of Chinese Medicine Fufang Zhenzhu Tiaozhi capsule (FTZ) in treating DCHD.Patients and MethodsThis study includes a 2-week run-in, 52-week treatment, and 52-week post-treatment follow-up. A total of 160 participants will be recruited and randomized into two groups. The treatment group will receive FTZ and basic treatment, while the control group will receive the placebo and basic treatment. The primary outcome is the combined outcome including the major adverse cardiovascular events, coronary restenosis, and unplanned revascularization. The combined secondary outcomes include all-cause mortality, acute coronary syndrome, ischemic stroke, heart failure, unplanned re-hospitalization mainly caused by acute complications of diabetes, other thromboembolic events, and TCM symptom indicators. The safety outcomes and adverse events will also be evaluated in this trial.DiscussionThis trial evaluates the clinical effectiveness and safety of FTZ in patients with DCHD. The results are important to further explore the effectiveness of the comprehensive strategy “Tiao Gan Qi Shu Hua Zhuo” (modulating Gan, trigging key metabolic system to resolve pathogenic factors such as phlegm retention and dampness) in the prevention and control of glucolipid metabolic disorders (GLMD) including DCHD and T2DM. On the other hand, this study is the first trial of FTZ to observe cardiovascular outcomes through long-term follow-up after treatment of DCHD, which is of great value.Trial RegistrationThis trial was registered in the Chinese Clinical Trial Registry on April 07, 2019 (No. ChiCTR1900022345).

66-LB: Real-Time Continuous Glucose Monitor (RTCGM) Use Associated with Decreased Diabetes Medical Costs for Patients with Type 2 Diabetes (T2D)

Background: RtCGM allows patients with type 2 diabetes to improve blood glucose control and reduce risk of serious acute and chronic complications of diabetes through continuous monitoring of real-time glucose levels, however little is known about the impact of rtCGM on diabetes-related medical costs in this population. Methods: A retrospective analysis of administrative claims data from the Optum Research Database was conducted. The T2D cohort included those on intensive insulin therapy (IIT), and non-intensive therapies, including basal insulin only, and non-insulin medications. Patients initiated treatment with rtCGM between October 1, 2017 and February 28, 2019 (index date= earliest observed pharmacy claim). Continuous health plan enrollment of 12 months prior to, and 6 months after index date was required. Individuals with evidence of pregnancy, or type 1 diabetes were excluded. Total diabetes-related medical costs were assessed during the pre-and post-index periods and expressed as change in per-person-per-month (PPPM) costs. Results: A total of 571 T2D patients met study inclusion criteria (average age = 51.2 (sd = 11.9) years, 46% female, 80% IIT). Average PPPM diabetes-related medical costs decreased by -$424, 95% CI -$816, -$31, p<0.035 after initiating rtCGM treatment (pre-index mean (SD) PPPM costs: $1,680 ($4,519); post-index: $1,256 ($3,679)). These reductions were driven, in part, by reductions in diabetes-related inpatient medical costs (-$358, 95% CI -$706, -10. p<.-044). Inpatient hospital stays were reduced on average -.006 PPPM and hospital days were reduced an average of -.042 PPPM. Conclusions: These findings provide real-world evidence that rtCGM use was associated with diabetes-related medical cost reductions in patients with T2D. Increased access to rtCGM for patients with T2D may help to reduce diabetes-related cost of care. Disclosure G. J. Norman: Employee; Self; Dexcom, Inc. M. L. Paudel: None. T. Bancroft: None. P. M. Lynch: Employee; Self; Dexcom, Inc.

1027-P: Sociodemographic, Clinical, and Treatment Factors Associated with Hyperglycemic Emergencies in Type 1 and Type 2 Diabetes

Hyperglycemic emergencies are life-threatening acute complications of diabetes. Efforts to prevent these events on the population level are hindered by inability to proactively identify those at highest risk. In this retrospective analysis of claims data of adults with type 1 and type 2 diabetes from OptumLabs Data Warehouse between 2014 and 2019, we calculated the adjusted (for age, sex, race/ethnicity, U.S. region) rates of hyperglycemic emergencies and examined their association with sociodemographic (age, sex, race/ethnicity, income), clinical (comorbidities), and treatment (diabetes medications, HbA1c level) factors using negative binomial regression.Among 16,621 adults with type 1 diabetes (age 46.7 [SD, 16.5] years, 48.9% female, 74.6% White) and 615,371 with type 2 diabetes (age 65.5 [SD, 11.9] years, 50.1% female, 56.4% White), adjusted rates of hyperglycemic emergencies were 47.8 (95% CI 43.9-52.0) and 3.7 (95% CI 3.5-3.8) per 1000 person-years, respectively. Table shows model results.Younger age, lower income, higher HbA1c, prior hyperglycemic and hypoglycemic emergencies, and presence of comorbidities (especially in type 2 diabetes) were associated with heightened risk of hyperglycemic emergencies. Event rates in type 2 diabetes increased over time. Proactive engagement of at-risk patients to address hyperglycemia may prevent these dangerous events.View largeDownload slideView largeDownload slide DisclosureR. G. Mccoy: None. K. Swarna: None. R. J. Galindo: Consultant; Self; Abbott Diabetes, Boehringer Ingelheim International GmbH, Eli Lilly and Company, Novo Nordisk, Sanofi US, Valeritas, Inc., Research Support; Self; Dexcom, Inc., Novo Nordisk. H. Van houten: None. P. J. O’connor: None. N. Shah: None.FundingNational Institute of Diabetes and Digestive and Kidney Diseases (K23DK114497)

1044-P: COVID-19 and Trends in Emergency Room (ER) Admissions for Diabetic Ketoacidosis (DKA) and Hypoglycemia

The COVID-19 pandemic affects many aspects of diabetes care including loss of access to healthcare due to clinic closures or insurance issues, fear of accessing care due to potential COVID exposures, and food/medication insecurity. Little is known about how ER visits for acute diabetic complications change as a result of this pandemic. An observational claims-based study was conducted to evaluate ER visits for DKA and hypoglycemia at the University of Michigan Health System. ER admissions with diagnoses of DKA and hypoglycemia were identified in 2020 and compared to 2017-19 (baseline). Since March 2020 (with the first COVID case identified in Michigan), the numbers of total ER admissions (both COVID and non-COVID related) have consistently remained lower than baseline (Figure 1A). While ER admission numbers for DKA (Figure 1B) and hypoglycemia (Figure 1C) were lower during the first wave of COVID (Mar-May), no consistent pattern has been observed in the second wave of COVID cases (Oct-).In summary, ER admissions for DKA and hypoglycemia decreased as much as 50% during the first, but not the second, waves of COVID cases. Further studies evaluating this complex psycho-social-medical phenomenon is in need.View largeDownload slideView largeDownload slide DisclosureY. Lin: None. C. R. Richardson: n/a. S. Fisher: None. G. Piatt: None. R. Pop-busui: Advisory Panel; Self; Novo Nordisk, Consultant; Self; Averitas Pharma, Bayer Inc., Boehringer Ingelheim Pharmaceuticals, Inc., Nevro Corp., Regenacy.FundingMichigan Center for Diabetes Translational Research (P30DK092926)

A study on the prevalence of hypoalbuminemia in the hospitalized type 2 diabetes mellitus patients with acute hyperglycemia and its correlation with the risk to ketosis in these patients

Background: Diabetes mellitus is a chronic metabolic disorder that diminishes the quality and life expectancy of the patients by impacting a significant morbidity and mortality due to its associated complications. Diabetic ketoacidosis is considered as one such acute life-threatening complication of diabetes that is considered a medical emergency.Methods: The study was conducted as a retrospective analysis of 65 patients diagnosed as Type 2 diabetes mellitus as per the criteria of American Diabetes Association 2019 were included in the study. After the ethical clearance, the study was conducted at the Employment State Insurance Corporation Hospital and Post Graduate Institute of Medical Science and Research, Chennai over a period of 6 months from October 2019 to March 2020. A statistical analysis was done and all the calculations were based on two-sided hypothesis with p<0.05 interpreted as significant.Results: The analysis of the study showed there was a significant prevalence of hypoalbuminemia (37%) among the patients with diabetes admitted with acute hyperglycemia. The occurrence of ketonuria among those patients with hypoalbuminemia were 62.5% [odds ratio (OR): 3.15, p value: 0.02].Conclusions: From the study, serum albumin levels has an inverse correlation in patients with acute hyperglycemia. Furthermore, low serum albumin harbingers the risk to ketosis in patients admitted with acute hyperglycemia thereby mirroring the relative insulin deficiency in these patients. Serum albumin can be used by the treating physician as a cost-effective tool and a marker for insulin reserve of the beta cell in an individual admitted with acute hyperglycemia, it can be used as a reliable indicator to identify those at risk to ketosis thereby to prevent and treat the dreaded diabetes related complications.

English

BACKGROUND Diabetic ketoacidosis (DKA) is a life-threatening condition of diabetes that is characterized by hyperglycaemia, ketoacidosis, and ketonuria. It happens when glucose's ability to enter cells for use as metabolic fuel is blocked by absolute or relative insulin deficiency. This causes liver to divide fat into ketones as a source of fuel. The purpose of the study was to assess the knowledge regarding prevention of signs and symptoms of diabetic ketoacidosis among diabetes patients in selected hospitals of Wardha district. METHODS A descriptive study was undertaken among 60 purposively selected patients of diabetes with diabetic ketoacidosis in Wardha district. Data was collected by using structured knowledge questionnaire during the month of May 2020. RESULTS The level of awareness among diabetes patients on how to avoid diabetic ketoacidosis was measured. The findings of study show that 49 (80 %) people had poor level of knowledge score and 11 (20 %) people had average level of knowledge score. Mean score was 4.38 ± 2.48 with mean percentage 24.35 ± 13.80. The association of knowledge score with educational status of diabetes patients from selected hospital. The tabulated ‘F’ values were 2.76 (df = 3, 56) which is much less than the calculated ‘F’ i.e., 8.73 at 5 % level of significance. Also, the calculated ‘P’=0.0001 which was much less than the acceptable level of significance i.e., ‘P’=0.05. Hence, it is interpreted that educational status of diabetes patients is statistically associated with their knowledge score. CONCLUSIONS Most patients with diabetes are poorly aware of the preventive measures of diabetic ketoacidosis. This study revealed several preventive gaps relating to an appropriate prevention strategy and acute diabetes complications. This research concluded that most patients with diabetes had insufficient knowledge of the signs and symptoms of diabetic ketoacidosis and its management. KEY WORDS Knowledge, Prevention, Sign, Symptoms, Diabetic Ketoacidosis, Diabetes Patients

Beyond the Fingerstick: Complications of Diabetes in the Acutely Ill Patient with Covid-19 with Lessons from Translation Biology and Therapeutics

The affliction that the Coronavirus Disease 2019 (COVID-19) pandemic has placed on the infrastructure of healthcare institutions across the globe permeates to the level of the provider, hampering clinical decision-making capacity and capability. Associated with the latter has been unprecedented, sweeping changes in biomedical equipment manufacturing, triage dynamics, and implementation of medical interventions in a landscape replete with clinical literature attempting to characterize features in COVID-19 patients. Preliminary assessments into the elements of the SARS-CoV-2 virus (the strain of coronavirus responsible for COVID-19) in addition to the delineation of patient flux pertaining to COVID-19 has identified diabetes as a prevalent comorbidity with increased mortality and increased disease burden in the acutely ill. The volume of patients with COVID-19 superimposed upon complicated diabetes exemplifies that insight into this association offers an expanded perspective of diabetes mellitus. Moreover, given the extensive organ compromise seen in COVID-19 in addition to the established notion that diabetes is a systemic syndrome of metabolism, an appraisal of the literature of medical management and precursory findings serve as bearings that help render clinical principles into viable treatments. In this review we investigate the array of contemporary literature surrounding COVID-19 with a perspective centered upon the management of acute diabetes complications, namely diabetic ketoacidosis and hyperosmolar hyperglycemic state, with emphases into translational biology and pharmacotherapeutics.

Incidence of Diabetic Ketoacidosis in Hospitalized COVID19 Patients With Type 2 Diabetes

Introduction: Diabetes is a disease of persistent hyperglycemia with a devastating complication and even death if left untreated. Morbidity and mortality often increased for any condition among patients with diabetes. Diabetic ketoacidosis (DKA) is an acute and life-threatening complication of diabetes. It can occur to type 2 diabetes (T2DM) under severe stress. Since the pandemic of Coronavirus disease 2019 (COVID19), that caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) began in Wuhan, Hubei China, in December 2019, more than 47 million infected cases reported leading to more than 1.2 million deaths reported worldwide. The presence of diabetes in COVID19 patients had a higher odd of severity and mortality of the COVID19 compared to patients without diabetes. Our study aims to identify the incidence rate of DKA in T2DM admitted with COVID19 in a tertiary care center. Evidence showed those populations at considerable risk for morbidity and mortality and no available data in Saudi Arabia. Method: A retrospective cohort of adult patients admitted for COVID19, with a diagnosis of T2DM or clinical evidence of DKA in a tertiary care center named King Fahad Medical City located in Riyadh in Saudi Arabia. The study involved a chart review. Data collected from the beginning of March 2020 till the end of June 2020. Results: Of 244 patients with T2DM admitted for COVID19, 190 patients were male, and 55 patients were female. The mean age was 59-year-old. out of 244 patients collected, 20 had developed DKA. The incidence rate of DKA was 8%. Number and percentage of male was 15 (71.4%) and female 6 (28.6%). Out of 20 patients admitted with DKA and COVID-19, two patients were not known to have diabetes prior to the presentation. Mortality resulted in 5 out of 20 during admission stay, represent 25% of all patients with DKA. Discussion: Here we report the first study in S.A. about DKA incidence in T2DM with COVID19 pneumonia. In the present study, an alarming observation of a higher incidence of DKA in a patient with type 2 diabetes and COVID19 infection as incidence reaches 8% over a short period of time while incidence worldwide area range was less than 2 per 1000 person-year for DKA in type 2 diabetes without COVID19. A study reported 20 % of patients who have diabetes and COVID19 presented ketosis developed DKA. We report the incidence of DKA in selected group. The mortality rate was not far from different evidence in the world. The mortality rate was 25% in the present study. In the USA, it reaches 30% of inpatient with hyperglycemia at presentation. Conclusion: DKA is a life-threatening complication, and it became worse when it is related to COVID19. The incidence of DKA and mortality related to COVID19 increased when DKA occurs for T2DM subjects. A more prospective study is warranted and a longer duration of the study to establish the accurate incidence and mortality rate.

Improving Care Delivery for Young Adults With Type 1 Diabetes via a Multi-Faceted Quality Improvement Interdisciplinary Intervention

Abstract Background: The transition from pediatric to adult type 1 diabetes (TID) care represents a vulnerable period for young adults (YA), and many are eventually lost to follow up. This can result in lost opportunities for patient education, worsened glycemic control and increased rates of acute diabetes complications. To address this, a multi-faceted quality improvement (QI) intervention was implemented at a YA T1D program with the goal of improving patient attendance and care delivery amongst YA with T1D. Methods: The intervention consisted of three main components: a transitional navigator, an interdisciplinary diabetes assessment flowsheet and virtual care via phone or video conference. These components were implemented at the YA T1D program using a stepwise approach beginning in 2019. The attendance of all patients seen between January 2017 and August 2020 were tracked monthly on a run chart to identify any shifts after each component was implemented. A pre-post analysis was also performed in new patients with a minimum follow up period of 12 months to compare secondary outcomes including A1c reduction at 12 months, incidence of diabetes-related ED visits/hospitalizations, incidence of severe hypoglycemia and psychosocial counselling rates. Results: A total of 2240 scheduled appointments was included in the primary analysis. Patient attendance improved from 59% to 79% (p<0.01) with virtual care, demonstrated by a shift in attendance sustained over 6 months after its implementation. Virtual care was utilized in 81.3% of appointments in the post-intervention period. Subgroup analysis showed the improvement in attendance was significant in follow up appointments (80% vs 59%, p<0.01), but there was no difference in attendance for initial consultations (67% vs 58%, p=0.45). Forty-two patients were included in the pre-post analysis (n=27 in the pre-intervention and n=15 in the post-intervention period). There were with no significant difference in baseline characteristics of the two groups. Mean patient age was 20.2±2.9 years. Males comprised of 28.5% of the study population. Mean duration of diabetes was 11.1±5.3 years, and baseline average A1c was 8.6±1.7%. Preliminary analysis demonstrated there was significant improvement in preconception counselling rate (76% vs 100%, p=0.048) following the intervention. There was no significant difference in A1c reduction at 12 months, incidence of diabetes-related ED visits/hospitalizations or incidence of severe hypoglycemia. Conclusion: Virtual care was effective in improving attendance for follow up appointments at a YA T1D clinic. Further data analysis for patients assessed in September to December 2020 is currently underway.

The CGM Experience of Minority Adults With Type 1 Diabetes in the South Bronx

Objective: To describe the state of type 1 diabetes (T1D) in minority adults in the South Bronx, and their experience with continuous glucose monitoring (CGM). Introduction: In a recent analysis of data from the Type 1 Diabetes Exchange Registry, one notable finding was the difference in metabolic control and use of diabetes technology in patients of different socioeconomic status and racial/ethnic backgrounds. With limited data available on Hispanic and Black patients, we sought to examine the use of and experience with continuous glucose monitoring (CGM) in our hospital system, which primarily serves a low-income, minority population in the South Bronx. Methods: 68 adults with T1D who attended the Endocrinology clinic at our hospital from 2017 to 2019 were identified. Patients were contacted by telephone to complete a questionnaire regarding CGM use and satisfaction. A retrospective chart review was conducted to obtain additional demographic and clinical information. Results: Out of 68 patients with T1D in the hospital database who were contacted, 47 patients completed the questionnaire. The age range was 23 to 63 years. 42.6% were male. 59.6% were Hispanic, 19.1% Black/African American (AA), 4.3% Caucasian, and 17% not specified. 87.2% had public insurance. Overall, 48.9% of patients were actively using CGM, 19.1% had discontinued use of CGM, and 31.9% had never used CGM. In Hispanic patients using CGM, mean HbA1C was 8.2% compared to 10.1% in Hispanic non-users. In Black/AA patients using CGM, mean HbA1C was 9.2% compared to 9.9% in Black/AA non-users. Hospitalizations for acute diabetes complications were lower in CGM users (4.3%) compared to non-CGM users (16.7%). Among active CGM users, 74% rated their satisfaction as “extremely satisfied” or “very satisfied.” Perceived benefits included the prevention of hypoglycemia and awareness of inappropriate food intake. Discussion: Our study population, mainly comprised of Hispanic and Black T1D adults, showed a higher CGM utilization rate than previously reported. After stratification by socioeconomic status, CGM utilization was reported to be as low as 16% in Hispanic and 10% in Black patients with household income <$50,000/year in the T1D Exchange Registry. By comparison, 49% of our studied population possessing similar demographics was actively using CGM. This study demonstrated that CGM acceptance was high in this largely minority, low-income population in the South Bronx, and was associated with lower A1C levels, high degree of patient satisfaction and reduction in diabetes-related hospitalizations. However, glycemic control remained suboptimal overall despite CGM access. Additional strategies to optimize the utility of CGM are needed to improve clinical outcomes such as HbA1C levels in minority T1D patients.

Important Drop in Rate of Acute Diabetes Complications in People With Type 1 or Type 2 Diabetes After Initiation of Flash Glucose Monitoring in France: The RELIEF Study.

The RELIEF study assessed rates of hospitalization for acute diabetes complications in France before and after initiation of the FreeStyle Libre system. A total of 74,011 patients with type 1 diabetes or type 2 diabetes who initiated the FreeStyle Libre system were identified from the French national claims database with use of ICD-10 codes, from hospitalizations with diabetes as a contributing diagnosis, or the prescription of insulin. Patients were subclassified based on self-monitoring of blood glucose (SMBG) strip acquisition prior to starting FreeStyle Libre. Hospitalizations for diabetic ketoacidosis (DKA), severe hypoglycemia, diabetes-related coma, and hyperglycemia were recorded for the 12 months before and after initiation. Hospitalizations for acute diabetes complications fell in type 1 diabetes (-49.0%) and in type 2 diabetes (-39.4%) following FreeStyle Libre initiation. DKA fell in type 1 diabetes (-56.2%) and in type 2 diabetes (-52.1%), as did diabetes-related comas in type 1 diabetes (-39.6%) and in type 2 diabetes (-31.9%). Hospitalizations for hypoglycemia and hyperglycemia decreased in type 2 diabetes (-10.8% and -26.5%, respectively). Before initiation, hospitalizations were most marked for people noncompliant with SMBG and for those with highest acquisition of SMBG, which fell by 54.0% and 51.2%, respectively, following FreeStyle Libre initiation. Persistence with FreeStyle Libre at 12 months was at 98.1%. This large retrospective study on hospitalizations for acute diabetes complications shows that a significantly lower incidence of admissions for DKA and for diabetes-related coma is associated with use of flash glucose monitoring. This study has significant implications for patient-centered diabetes care and potentially for long-term health economic outcomes.

Clinical and Biochemical Characteristics and Treatment Outcomes of Ketosis-Prone Diabetes: The Remission Prone Diabetes.

BackgroundDiabetic ketoacidosis (DKA) is one of the severe acute complications of diabetes. It has long been considered a key clinical characteristic of type 1 diabetes mellitus (T1DM) with severe and irreversible deficient insulin levels. Ketosis-prone diabetes (KPD) has pathophysiology close to T2DM but shows signs and symptoms associated with T1DM. In general, patients with ketosis-prone diabetes display elevated glucose and ketone levels; also, a higher hemoglobin A1C than conventional T2DM.ObjectivesThe current research aimed to elucidate the clinical presentation and outline a management plan for KPD in the Indian population.MethodsThe present case series is a descriptive, prospective, and observational case series on six unprovoked cases of KPD. They were managed using the standard protocol of DKA management.ResultsThe recruited cases followed a set pattern of very high insulin requirement at diagnosis. On follow-up, the insulin requirement progressively declined, and all of the cases were able to stop insulin therapy after a mean period of four weeks. None of the cases presented any organ damage at diagnosis. There was no recurrence of DKA during the two-year follow-up. All of the cases had normal liver and renal functions. Autoantibodies were negative in all of the cases.ConclusionsKetosis-prone diabetes is the most under-recognized and under-diagnosed among all types of diabetes. Its recognition is of utmost importance as the approach of its treatment varies widely from that of the conventional type of diabetes. Proper follow-up, especially in unprovoked cases of DKA with obese phenotype, could help elucidate this rare entity of KPD where insulin can be stopped and maintain normoglycemia for a substantial period without insulin.

Effect of COVID-19 on the clinical course of diabetic ketoacidosis (DKA) in people with type 1 and type 2 diabetes.

ObjectiveCOVID-19 in people with diabetes is associated with a disproportionately worse prognosis. DKA is an acute complication of diabetes with a mortality rate of approximately 0.67%. Little is known about the natural history of DKA in the presence of COVID-19. This study aimed to explore the effects of COVID-19 on presentation, clinical course and outcome in patients presenting with DKA.DesignRetrospective cohort study.MethodsAll patients treated for DKA between 1 March 2020 and 30 May 2020 were included. Patients were categorised as COVID-positive or COVID-negative based on the swab test. A pre-COVID group was established using data from 01 March 2019 to 30 May 2019 as external control. Data regarding demographics, diabetes type, pH, bicarbonate, lactate, glucose, DKA duration, complications and outcome were collected.ResultsA total of 88 DKA episodes were included in this study. There was no significant difference in the severity or duration of DKA between the three groups. COVID-positive T1DM were more hyperglycaemic on admission compared to COVID-negative and pre-COVID patients. There was an over representation of T2DM in COVID-positive patients with DKA than in pre-COVID or COVID-negative groups.ConclusionCOVID-19 appears to influence the natural history of DKA differently in T1DM and T2DM. Patients with T1DM and COVID-19 presented with more hyperglycaemia (60 mmol/L (35.9–60.0) vs 31.4 mmol/L (28.0–39.1) vs 24 mmol/L (20.2–33.75), respectively). Patients with T2DM were unusually presenting in DKA when infected with COVID-19 with greater ICU need and higher mortality rates. A collaborative, multi-centre study is needed to provide more definitive results.

Euglycemic Diabetic Ketoacidosis and Sodium-Glucose Cotransporter-2 Inhibitors: A Focused Review of Pathophysiology, Risk Factors, and Triggers.

Diabetic ketoacidosis (DKA) is an acute and significant life-threatening complication of diabetes. The association of sodium-glucose cotransporter-2 inhibitors (SGLT2i) with euglycemic diabetic ketoacidosis (EDKA) has been well reported. This literature review was conducted to understand the mechanism of EDKA and identify the potential risk factors and precipitants for patients taking SGLT2i. After reviewing the published literature between 2010 and 2020, 32 articles are included in the final review. The underlying mechanism is mainly enhanced lipolysis and ketone body reabsorption. SGLT2i also stimulates pancreatic alpha cells and inhibits beta cells, causing an imbalance in glucagon/insulin levels, further contributing to lipolysis and ketogenesis. Most patients were diagnosed with blood glucose less than 200 mg/dL, blood pH <7.3, increased anion gap, increased blood, or urine ketones. Perioperative fasting, pancreatic etiology, low carbohydrate or ketogenic diet, obesity, and malignancy are identified precipitants in this review. As normoglycemia can conceal the underlying acidosis, physicians should be cognizant of the EDKA diagnosis and initiate prompt treatment. Patient education on risk factors and triggers is recommended to avoid future events.

Differences in presentation, severity and management of DKA in type 1 and type 2 diabetes during the COVID-19 pandemic

COVID-19 infection in people with diabetes is associated with a disproportionately increased risk of complications and mortality.[1][1] Diabetic ketoacidosis (DKA) is an acute complication of diabetes.[2,3][2] Little is known about DKA in the presence of COVID-19 infection. This study aimed to

Comparison of compliance and outcomes in adolescents with type 1 diabetes mellitus attending a co-located pediatric and transition diabetes service

Abstract Objectives Adolescence is a challenging period for diabetes management, particularly when transitioning to adult care. There are reports highlighting concerns that transition to adult care may lead to poor glycemic control and clinic engagement. Our aim was to determine if a co-located pediatric and transition diabetes service would lead to better transition outcomes. Methods A retrospective medical records review was conducted on patients with type 1 diabetes attending a transition clinic in a metropolitan teaching hospital in Sydney, Australia. Patients referred from the hospital’s co-located pediatric diabetes clinic to the transition clinic were compared to those referred from external sources regarding important clinical outcomes such as glycosylated haemoglobin (HbA1c), clinic attendances, and complication rates between referral sources. Confounders such as age, gender, duration of diabetes and socioeconomic status were considered. Results Data was collected from 356 patients of which 121 patients were referred from the co-located pediatric diabetes clinic (IRG) and 235 patients from external sources (ERG). Improvements in HbA1c were only seen in the ERG at 6 and 12 months (p&lt;0.001). Altogether 93% attended one or more medical appointments in the IRG compared to 83% in the ERG (p=0.03). There were more admissions for acute diabetes complications (17 vs. 8%, p=0.01) and more microvascular complications (20 vs. 9%, p&lt;0.01) in the IRG vs. ERG group. Conclusions Although co-location of a pediatric and transition clinic improved medical engagement, this did not equate to better glycemic control or complication rates. Further research is warranted to determine what other strategies are required to optimise the transition process in diabetes care.

Profile and outcomes of patients admitted with hyperglycemic emergencies in the Buea Regional Hospital in Cameroon.

Introductionhyperglycemic emergencies (diabetic ketoacidosis and hyperglycemic hyperosmolar state) are the most common serious acute metabolic complications of diabetes which result in significant morbidity and mortality. There is paucity of data on hyperglycemic emergencies in Cameroon. The objective of this study was to investigate the precipitants and outcomes of patients admitted for hyperglycemic emergencies in the Buea Regional Hospital in the South West Region of Cameroon.Methodsin this retrospective study the medical records of patients admitted for hyperglycemic emergencies between 2013 and 2016 in the medical unit of the Buea Regional Hospital were reviewed. We extracted data on demographic characteristics, admission clinical characteristics, precipitants, and treatment outcomes. Logistic regression was used to determine predictors of mortality.Resultsdata were available for 60 patients (51.7% females) admitted for hyperglycemic emergencies. The mean age was 55.2±16.3 (range 18-86). Overall there were 51 (85%) cases of hyperosmolar hyperglycemic state. Twenty six (43.3%) of the patients had hypertension. The most common precipitants of hyperglycemic emergencies were infections (41.7%), newly diagnosed diabetes (33.3%) and non-adherence to medications (33.3%). Mean admission blood glucose was 574mg/dl±70.0mg/dl. The median length of hospital stay was 6 days. Overall case fatality rate was 21.7%. Six (46.2%) deaths were related to infections. Predictors of mortality were a Glasgow coma score <13(p<0.001), a diastolic blood pressure <60 mmHg (p=0.034) and a heart rate >90(0.057) on admission.Conclusionadmission for hyperglycemic emergencies in this semi-urban hospital is associated with abnormally high case fatality. Infections, newly diagnosed diabetes and non-adherence to medications are the commonest precipitants of hyperglycemic emergencies. Public health measures to reduce morbidity and mortality from hyperglycemic crisis are urgently needed.

The Impact of the COVID-19 Pandemic on Diabetes Care in Ontario, Canada

Importance: The first wave of COVID-19 pandemic and related public health prevention measures caused major disruptions in delivery of routine care and may have had an impact on quality of care for chronic conditions such as diabetes.Objective: To evaluate the extent to which structure, process and outcome measures in diabetes care changed during the first wave of the pandemic.Design: Observational cohort study.Setting: Province of Ontario, Canada.Participants: All community-living Ontario residents over 20 years of age with diagnosed diabetes divided into three cohorts - pandemic cohort, alive March through August 2020 (n=1,393,404), reference cohort 1, alive March through August 2019 (n=1,415,490) and reference cohort 2, alive September through February 2019 (n=1,444,000).Intervention: The pandemic cohort was defined as the exposed group and the other two as controls.Main outcome measures: Visits to general practitioners (GP) and specialists, eye examinations, completed HbA1C and lipid blood tests, filled prescriptions for ACE/ARB or statins, and admissions to emergency departments (ED) and hospitals for acute and chronic diabetes complications over each six-month period.Results: Those in the pandemic cohort had a 40.8% (95% CI: 40.5, 41) absolute reduction in in-person GP visits (RRR 47% CI: 47, 47), a 7.7% (CI: 7.52, 8.02) reduction in specialists in-person visits (RRR 13% CI: 13,13). They had a 5% reduction (CI 4.8, 5.1) in eye exams (RRR 43% CI: 43,44) a 19.0% (CI 18.7, 19.2) drop in HbA1C testing (RRR 28% CI: 28,29) , and 14.9% (14.7, 15.2) in LDL testing (RRR 31% CI: 31,31) respectively. They had similar rates of filled prescriptions for ACE/ARB and statins (ARR 1.3% CI: 1.3, 1.3). ED or hospital admissions for acute complications decreased by an absolute 0.33% (CI: 0.27, 0.4) (RRR 16% CI: 14,17) and 0.16% (CI: 0.09, 0.23) (RRR 9% CI: 0.9, 0.93) for chronic complications.Conclusion: During the first six months of the pandemic, the proportion of individuals with diabetes in Ontario who had face-to-face visits with GP and specialists, underwent eye exams and had diabetes-related blood tests decreased compared to pre-pandemic time periods. Although they also had fewer ED or hospital stays for diabetes complications, this may reflect constraints on use of or access to those sectors rather than better outcomes. These results suggest that the quality of care for individuals with diabetes in Ontario may have declined during the early stages of the pandemic. Efforts should be made to further examine quality of care issues related to the pandemic and to initiate strategies to make up for the deficits identified, resulting from public stay-at-home orders. Actual health impacts and consequences of these care disruptions during the early months of the pandemic and beyond, require further study.Funding Information: This work was funded in part by CIHR through the SPOR Primary and Integrated Health Care Innovation Network in Ontario, the Ontario SPOR Support Unit and through support for Dr. Moin as a Postdoctoral Fellow by the University of Toronto Institute for Pandemics. Declaration of Interests: None to report.Ethics Approval Statement: University of Toronto REB# 41386.

Characteristics and Clinical Course of Diabetes of the Exocrine Pancreas: A Nationwide Population-Based Cohort Studybrief Title: Diabetes of the Exocrine Pancreas

Background: The natural course of diabetes of the exocrine pancreas (DEP) is not well established. We aimed to compare the risk of insulin initiation, diabetic complications, and mortality between DEP and type 2 diabetes. Methods: Using the Korean National Health Insurance Service–Health Screening Cohort between 2012-2017, we divided diabetic patients into those with diabetes without prior pancreatic disease (indicated type 2 diabetes, n=153 894) and diabetes following pancreatic disease (indicated DEP, n=3661). ICD-10 codes and pharmacy prescription information were used to define type 2 diabetes, DEP, and acute and chronic diabetes complications. Reverse Kaplan-Meier curves were produced to compare insulin use over time between groups. We created logistic regression models for odds of progression to diabetic complications and mortality. Findings: DEP was associated with a higher risk of insulin use than type 2 diabetes (adjusted hazard ratio 1·25 at 1 year [95% confidence interval 1·16–1·35], p<0·0001; at 5 years 1·28 [1·20–1·35], p<0·0001). Individuals with DEP showed higher risks of hypoglycaemia (odds ratio 1·82 [1·52–2·18], p<0·0001), diabetic neuropathy (1·37 [1·27–1·48], p<0·0001), nephropathy (1·34 [1·24–1·45], p<0·0001), retinopathy (1·12 [1·03–1·22], p=0·0110), cardiovascular disease (1·50 [1·39–1·61], p<0·0001), cerebrovascular disease (1·24 [1·14–1·34], p<0·0001), and peripheral artery disease (1·24 [1·15–1·33], p<0·0001). All-cause mortality was higher in those with DEP (1·52 [1·37–1·70], p<0·0001) than in those with type 2 diabetes. Interpretation: DEP is more likely to require insulin therapy than type 2 diabetes. Hypoglycaemia, micro- and macrovascular complications, and all-cause mortality events are higher in DEP compared to type 2 diabetes. Awareness of these differences in the natural history of DEP may better enable clinicians to address the challenges posed by this diabetes sub-type and better achieve glycaemic control targets, avoid hypoglycaemia, and monitor and prevent complications. Funding: This study was funded by the National Research Foundation of Korea Ministry of Science and ICT (No. NRF-2018R1C1B5044056) and Korea Medical Institute. Declaration of Interest: None to declare. Ethical Approval: This study was approved by the Institutional Review Board of Ajou University Hospital (AJIRB-MED-EXP-19-106]