Prevention Of Diabetic Ketoacidosis Research Articles

Ketone Management in Pediatric Diabetes Centers in the USA: Current Practices and a Call for Improved Standardization

Introduction: Diabetic ketoacidosis (DKA) is the leading cause of mortality among youth with type 1 diabetes (T1D). Guidelines for DKA prevention exist; however, specific guidance about when to check ketones and how to manage youth using insulin pumps and automated insulin delivery (AID) systems is lacking. Methods: A 35-item online survey exploring clinical ketone management practices for youth with T1D in the USA was distributed to diabetes healthcare professionals (HCPs). Survey responses, including multiple-choice and Likert scale questions, were summarized and rates of agreement and disagreement (Likert scale 4, 5 vs. 1, 2, 3) are reported. Results: In total, 123 HCPs (51% physicians, 26% diabetes educators, 19% nurse practitioners) from 47 institutions completed the survey. Seventy percent worked at academic specialty centers. Ninety-seven percent reported >50% continuous glucose monitoring use in their clinic and 72% reported >50% insulin pump use. Although 79% reported having ketone management protocols, the level and duration of hyperglycemia at which ketone monitoring was advised ranged from >200 to 350 mg/dL and from 0 min to >6 h of duration. While 72% had distinct ketone management protocols for pump users, only 29% had specific protocols for AID. Sixty-two percent agreed that DKA due to infusion site failure was a significant problem in their practice, and 70% agreed there was a need to standardize ketone management guidelines. Conclusions: The preventable nature and high incidence of DKA highlight the need to build consensus for clinical ketone management and to develop tools to facilitate management, especially as the use of diabetes technologies continues to increase.

Continuous ketone monitoring: Exciting implications for clinical practice.

Diabetic ketoacidosis (DKA) is a life-threatening complication usually affecting people with type 1 diabetes (T1D) and, less commonly, people with type 2 diabetes. Early identification of ketosis is a cornerstone in DKA prevention and management. Current methods for ketone measurement by people with diabetes include capillary blood or urine testing. These approaches have limitations, including the need to carry testing strips that have a limited shelf life and a requirement for the user to initiate a test. Recent studies have shown the feasibility of continuous ketone monitoring (CKM) via interstitial fluid with a sensor inserted subcutaneously employing an enzymatic electrochemical reaction. Ketone readings can be updated every 5 minutes. In the future, one would expect that commercialized devices will incorporate alarms linked with standardized thresholds and trend arrows. Ideally, to minimize the burden on users, CKM functionality should be integrated with other devices used to implement glucose management, including continuous glucose monitors and insulin pumps. We suggest CKM provision to all at risk of DKA and recommend that the devices should be worn continuously. Those who may particularly benefit are individuals who have T1D, are pregnant, on medications such as sodium-glucose linked transporter (SGLT) inhibitors that increase DKA, people with recurrent DKA, those with T1D undertaking high intensity exercise, are socially or geographically isolated, or those on low carbohydrate diets. The provision of ketone profiles will provide important clinical insights that have previously been unavailable to people living with diabetes and their healthcare professionals.

Induction of Diabetes Mellitus Using Alloxan in Sprague Dawley Rats.

The use of rodent models for diabetes, particularly with pancreatic islet transplantation, has been prevalent in various preclinical trials. The purpose of this study is to establish a diabetes mellitus (DM) model in Sprague Dawley (SD) rats using alloxan evaluated by assessing alloxan dosage, the induction rate of diabetes, and glucose stability through insulin treatment. Over the course of 13 experimental rounds, diabetes was induced in 86 SD rats using alloxan at concentrations of 200 mg/kg (16 rats) or 150 mg/kg (70 rats). Various parameters, including diabetes induction rates, average insulin doses, extent of weight loss, and adverse effects such as diabetic ketoacidosis (DKA), were measured. The administration of 200 mg/kg of alloxan in rats resulted in severe diabetes induction, leading to DKA in three individuals, despite daily insulin glargine administration, DKA prevention was unsuccessful. The stability of alloxan decreases over time, especially when refrigeration is compromised during weighing. In the group treated with 150 mg/kg of alloxan, the diabetes induction rate was 83%. The average insulin dose was 2.21 units/kg/day. In contrast, the group treated with 200 mg/kg of alloxan exhibited a diabetes induction rate of 81% with a statistically significant higher average insulin requirement at 7.58 units/kg/day compared to 150 mg/kg of alloxan. Inducing diabetes in rats with 150 mg/kg of alloxan is considered more suitable for creating a diabetes model for xenogeneic islet transplantation compared to using 200 mg/kg of alloxan. This is due to fewer complications related to DKA or hyperglycemia and reduced need for exogenous insulin treatment.

Hyperglycaemic crises in adults with diabetes: a consensus report

The American Diabetes Association (ADA), European Association for the Study of Diabetes (EASD), Joint British Diabetes Societies for Inpatient Care (JBDS), American Association of Clinical Endocrinology (AACE) and Diabetes Technology Society (DTS) convened a panel of internists and diabetologists to update the ADA consensus statement on hyperglycaemic crises in adults with diabetes, published in 2001 and last updated in 2009. The objective of this consensus report is to provide up-to-date knowledge about the epidemiology, pathophysiology, clinical presentation, and recommendations for the diagnosis, treatment and prevention of diabetic ketoacidosis (DKA) and hyperglycaemic hyperosmolar state (HHS) in adults. A systematic examination of publications since 2009 informed new recommendations. The target audience is the full spectrum of diabetes healthcare professionals and individuals with diabetes.

Hyperglycemic Crises in Adults With Diabetes: A Consensus Report.

The American Diabetes Association (ADA), European Association for the Study of Diabetes (EASD), Joint British Diabetes Societies for Inpatient Care (JBDS), American Association of Clinical Endocrinology (AACE), and Diabetes Technology Society (DTS) convened a panel of internists and diabetologists to update the ADA consensus statement on hyperglycemic crises in adults with diabetes, published in 2001 and last updated in 2009. The objective of this consensus report is to provide up-to-date knowledge about the epidemiology, pathophysiology, clinical presentation, and recommendations for the diagnosis, treatment, and prevention of diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) in adults. A systematic examination of publications since 2009 informed new recommendations. The target audience is the full spectrum of diabetes health care professionals and individuals with diabetes.

Nanowire Array Breath Acetone Sensor for Diabetes Monitoring.

Diabetic ketoacidosis (DKA) is a life-threatening acute complication of diabetes characterized by the accumulation of ketone bodies in the blood. Breath acetone, a ketone, directly correlates with blood ketones. Therefore, monitoring breath acetone can significantly enhance the safety and efficacy of diabetes care. In this work, the design and fabrication of an InP/Pt/chitosan nanowire array-based chemiresistive acetone sensor is reported. By incorporation of chitosan as a surface-functional layer and a Pt Schottky contact for efficient charge transfer processes and photovoltaic effect, self-powered, highly selective acetone sensing is achieved. The sensor has exhibited an ultra-wide acetone detection range from sub-ppb to >100 000ppm level at room temperature, covering those in the exhaled breath from healthy individuals (300-800ppb) to people at high risk of DKA (>75ppm). The nanowire sensor has also been successfully integrated into a handheld breath testing prototype, the Ketowhistle, which can successfully detect different ranges of acetone concentrations insimulated breath samples. The Ketowhistle demonstrates the immediate potential for non-invasive ketone monitoring for people living with diabetes, in particular for DKA prevention.

Use of teplizumab in children and adolescents at risk of type 1 diabetes: perspectives of parents and caregivers from an Italian Pediatric Diabetes Center.

In view of the imminent introduction of a novel category of disease-modifying treatments for type 1 diabetes (T1D) in European countries, it becomes imperative to understand the existing awareness and viewpoints of parents and caregivers of children and adolescents predisposed to T1D. This study aims to evaluate the perspectives of a cohort of parents and caregivers regarding using teplizumab to delay the onset of T1D in predisposed children and adolescents. This single-center study used a survey-based approach. Parents or caregivers of children and adolescents with T1D having at least one additional child without T1D answered 15 questions assessing their awareness about teplizumab, their potential willingness to provide consent for its administration in case of eligibility, and their expectations regarding potential outcomes. Approximately half of the participants (52.6%) expressed readiness to consent to teplizumab administration for their child if the prescription criteria were met in the future. Only 6.3% of parents claimed detailed knowledge about this innovative medication. Notably, parents with prior experience of diabetic ketoacidosis (DKA) demonstrated a higher inclination to consent to teplizumab treatment (p = 0.018). Our findings underscore the necessity for comprehensive awareness campaigns spreading the current evidence concerning teplizumab in terms of both effectiveness and possible side effects. Additionally, our study reinforces the pivotal role of DKA prevention in successfully integrating disease-modifying treatments into clinical practice.

The Prevention of Diabetic Ketoacidosis in Patients with Type 2 Diabetes on Sodium-Glucose Transport Protein 2 Inhibitors

Background: Sodium-Glucose Transport Protein 2 Inhibitors (SGLT2Is) effectively control diabetes. Diabetic ketoacidosis (DKA) has been reported as a life-threatening adverse effect due to SGLT2Is use. Aim: This study aims to review the current evidence of incidence, predisposing factors and the prevention of DKA in T2DM patients on SGLT2Is use. Methods and Materials: Two reviewers have conducted a search strategy of studies published in English between August 2012 and November 2020, in EBSCOhost, Google Scholar, PubMed, Science Direct and Wiley. Two reviewers independently assessed the eligibility and quality of the studies and extracted the data. Results: 85 studies were identified in the initial search; 75 records were removed and finally, 10 studies were included. Only studies discussing the prevention of DKA in T2DM patients on SGLT2Is were selected, extracted and categorized into main domains that included SGLT2Is use inT2DM patients and DKA (50%), SGLT2Is use in T2DM patients (20%), the clinical presentation of DKA (20%) and DKA prevention (10%). Six studies showed SGLT2Is increased the risk of DKA with very low rates in two studies. The precipitating factors of DKA in all included studies were revealed asstopping or reducing insulin, trauma, infection, surgery, severe acute illness, vigorous exercise, dehydration, low carbohydrate intake and excessive alcohol intake. In two studies DKA can be prevented by wakefulness and education, in one study by closed follow-up, in one study by regular monitoring and adjustment of medications and in two studies by recognition of patients at risk. Conclusions: This review summarized the prevention of DKA in T2DM patients on SGLT2Is use with consideration of incidence, a summary of evidence and predisposing factors. Physicians, health care providers and patients should be aware of SGLT2Is use, regular follow up, precipitating factors, symptoms, signs and prevention of DKA. Keywords: Sodium-Glucose Transport Protein 2 Inhibitors SGLT2Is, Type 2 diabetes mellitus, Diabetic Ketoacidosis, Scoping Review.

Diabetic Ketoacidosis at Diagnosis in Youth with Type 1 Diabetes Is Associated with a Higher Hemoglobin A1c Even with Intensive Insulin Management.

Introduction: Diabetic ketoacidosis (DKA) at diagnosis is associated with short- and long-term complications. We assessed the relationship between DKA status and hemoglobin A1c (A1c) levels in the first year following type 1 diabetes (T1D) diagnosis. Research Design and Methods: The Pilot Teamwork, Targets, Technology, and Tight Control (4T) study offered continuous glucose monitoring to youth with T1D within 1 month of diagnosis. A1c levels were compared between historical (n = 271) and Pilot 4T (n = 135) cohorts stratified by DKA status at diagnosis (DKA: historical = 94, 4T = 67 versus without DKA: historical = 177, 4T = 68). A1c was evaluated using locally estimated scatter plot smoothing. Change in A1c from 4 to 12 months postdiagnosis was evaluated using a linear mixed model. Results: Median age was 9.7 (interquartile range [IQR]: 6.6, 12.7) versus 9.7 (IQR: 6.8, 12.7) years, 49% versus 47% female, 44% versus 39% non-Hispanic White in historical versus Pilot 4T. In historical and 4T cohorts, DKA at diagnosis demonstrated higher A1c at 6 (0.5% [95% confidence interval (CI): 0.21-0.79; P < 0.01] and 0.38% [95% CI: 0.02-0.74; P = 0.04], respectively), and 12 months (0.62% [95% CI: -0.06 to 1.29; P = 0.07] and 0.39% [95% CI: -0.32 to 1.10; P = 0.29], respectively). The highest % time in range (TIR; 70-180 mg/dL) was seen between weeks 15-20 (69%) versus 25-30 (75%) postdiagnosis for youth with versus without DKA in Pilot 4T, respectively. Conclusions: Pilot 4T improved A1c outcomes versus the historical cohort, but those with DKA at diagnosis had persistently elevated A1c throughout the study and intensive diabetes management did not mitigate this difference. DKA prevention at diagnosis may translate into better glycemic outcomes in the first-year postdiagnosis. Clinical Trial Registration: clinicaltrials.gov: NCT04336969.

Clinical characteristics and severity of diabetic ketoacidosis: A cross-sectional study from a tertiary hospital in Ghana.

Diabetic ketoacidosis (DKA) is a common, severe and often fatal complication of diabetes. This study aimed to investigate the clinical characteristics and precipitants of DKA, as well as factors associated with DKA severity in Ghanaian patients. Cross-sectional study of the medical records of all 70 adult patients >18 years managed for DKA in the adult emergency room of Korle-Bu Teaching Hospital in Ghana from March 2019 to July 2019. DKA diagnosis was based on hyperglycaemia >11.0 mmol/L, ketonuria (more than 2+) plus acidaemia of (pH < 7.3) or bicarbonate (HCO3 - ) <15.0 mmol/L. However, when serum bicarbonate and pH were not available, clinical signs of acidosis, for example, Kussmaul breathing aided in the diagnosis. DKA severity was assessed based on the Joint British Diabetes Societies (JBDS) guidelines of factors suggestive of severe DKA. Multivariable logistic regression was used to determine the factors associated with DKA severity. Odds ratio and 95% confidence interval for factors associated with DKA severity were determined. The mean (±standard deviation) age, diabetes duration and blood sugar at admission were 44.06 (±16.23) years, 7.19 (±6.04) years and 26.37 (±6.70) mmol/L, respectively. Females comprised 51.4% of the study population. The most common presenting symptoms were generalised weakness (30.0%) and fever (14.3%). The major precipitants were infection (70.0%) and non-compliance (22.9%). Overall, 71.4% of participants had features suggestive of severe DKA. In a multivariable regression model, Type 2 diabetes was associated with over fourfold decreased odds of severe DKA (OR 0.23, 95% CI [0.07-0.76], p = 0.016). Patient education on prevention of DKA was documented for only 18.6% of patients before being discharged. In this study, more than 70% of the study participants had features suggestive of severe DKA, with infection being the most common precipitant of DKA. 51.4% of patients had Type 2 diabetes which was associated with a statistically lower risk of severe DKA. Female sex tended to be positively associated with DKA severity. In a setting where the venous/arterial pH and bicarbonate levels may be inaccessible and/or unaffordable, using clinical features as found in the JBDS guidelines may help categorise patients and escalate care when needed. Indeed it may be useful to validate the use of the JBDS criteria for use in such settings.

To study risk factors and biochemical profile of diabetic ketoacidosis patients with special emphasis on serum amylase

Background: Diabetes mellitus (DM) is a complex endocrinological disorder with altered metabolism of blood glucose. Diabetic ketoacidosis (DKA) is one of the life-threatening acute complications of DM that mainly occurs in type 1 diabetes patients, as well as in some patients with type 2 diabetes. The mortality rate associated with DKA depends on the experience of the treating hospital in dealing with this condition; thus, it is critical that patients detect DKA and get medical help as soon as possible. Aims and Objectives: To study risk factors for DKA, clinical and biochemical profile of DKA patients. Correlation between serum amylase level, serum bicarbonate level and mean duration of hospital stay. Materials and Methods: A cross-sectional analytical study was carried out on 100 DKA patients in the Department of Medicine, SGMH Rewa, Madhya Pradesh from January 2021 to June 2022. The data extracted included clinical presentation, precipitating factors, laboratory profile, complications, and hospitalization outcomes. Results: Of the 100 patients admitted for DKA; 70 had type 2 diabetes (70%) and 30 (30%) were type I diabetes. The average age at the time of presentation was 48.61±19.59 years. The commonest precipitating factor was infection (38%) followed by other factors (62%). The most common clinical features at the time of presentation were altered sensorium, fever, vomiting, polyuria, polydipsia, weakness, lethargy, myalgia, headache, anorexia, abdominal pain, and orthopnea. The values for RBS, HCO3, and pH were 525.0±62.4, 12.6±2.69, and 7.14±0.31, respectively. There was no significant difference in clinical and biochemical profile of patients with type 1 and type 2 diabetes. The mortality rate was 3% and factors found to be significant predictors were comorbid condition, severity of mental status, severity of dehydration, RBS at the time of presentation, and severe acidosis. Conclusion: The most common precipitating factors are infection and omission of insulin or irregular treatment. The most common clinical features at the time of presentation are nausea, vomiting, abdominal pain, headache, and dehydration. There is no significant difference in the clinical and biochemical profile of patients with type 1 and type 2 diabetes. The mortality rate in DKA is 3% and the most notable predictors of poor prognosis are; severity of altered sensorium, severity of comorbid condition, severe dehydration, severe acidosis, and identification and treatment of precipitating factors are more important. Patient education plays a crucial role in the prevention of DKA.

General population screening for paediatric type 1 diabetes-A qualitative study of UK professional stakeholders.

Identifying children at risk of type 1 diabetes allows education for symptom recognition and monitoring to reduce the risk of diabetic ketoacidosis at presentation. We aimed to explore stakeholder views towards paediatric general population screening for type 1 diabetes in the United Kingdom (UK). Qualitative interviews were undertaken with 25 stakeholders, including diabetes specialists, policymakers and community stakeholders who could be involved in a future type 1 diabetes screening programme in the UK. A thematic framework analysis was performed using the National Screening Committee's evaluative criteria as the overarching framework. Diabetic ketoacidosis prevention was felt to be a priority and proposed benefits of screening included education, monitoring and helping the family to better prepare for a future with type 1 diabetes. However, diabetes specialists were cautious about general population screening because of lack of evidence for public acceptability. Concerns were raised about the harms of living with risk, provoking health anxiety and threatening the child's right to an 'open future'. Support systems that met the clinical and psychological needs of the family living with risk were considered essential. Stakeholders were supportive of research into general population screening and acknowledged this would be a priority if an immunoprevention agent were licensed in the UK. Although stakeholders suggested the harms of UK paediatric general population screening currently outweigh the benefits, this view would potentially be altered if prevention therapies were licensed. In this case, an evidence-based screening strategy would need to be formulated and public acceptability explored.

Clinical profile and outcome of critically ill COVID-19 patients with diabetic ketoacidosis: A single-centre cross-sectional study in South India.

Clinical profile and outcome of critically ill COVID-19 patients with diabetic ketoacidosis: A single-centre cross-sectional study in South India.

Incidence and presentation of new-onset type 1 diabetes in children and adolescents from Germany during the COVID-19 pandemic 2020 and 2021: Current data from the DPV Registry

AimsTo determine whether the incidence of type 1 diabetes mellitus (T1D), autoantibody-negative diabetes, and diabetic ketoacidosis (DKA) at diabetes onset in 2020 and 2021 changed when compared to long-standing trends. MethodsOur study is based on diabetes manifestation data of the 0.5–<18-year-old children/adolescents from the German multicenter Diabetes Prospective Follow-up Registry. Based on long-term pre-pandemic trends from 2011 to 2019, we estimated adjusted incidence rate ratios (IRR) for T1D and DKA, and prevalence rate ratios (PRR) regarding autoantibody status with 95 % confidence intervals (CI) for the years 2020 and 2021 (observed versus predicted rates), using multivariable negative binomial or beta-binomial regression, respectively. ResultsWe analyzed data of 30,840 children and adolescents with new-onset T1D. The observed incidences were significantly higher than the predicted incidences (IRR2020 1.13 [1.08–1.19]; IRR2021 1.20 [1.15–1.26]). The prevalence of autoantibody-negative diabetes did not change (PRR2020 0.91 [0.75–1.10]; PRR2021 1.03 [0.86–1.24]). The incidence of DKA during the pandemic was higher than predicted (IRR2020 1.34 [1.23–1.46]; IRR2021 1.37 [1.26–1.49]). ConclusionsAn increase in the incidences of T1D and DKA, but not of autoantibody-negative diabetes was observed during both pandemic years. Further monitoring and efforts for DKA prevention at onset are necessary.

DKA Prevention and Insulin Pumps: Lessons Learned From a Large Pediatric Pump Practice.

This purpose of the study was to describe recent diabetic ketoacidosis (DKA) incidence data in youth with type 1 diabetes using insulin pumps and the impact of continuous glucose monitors (CGMs) on DKA rates. DKA data were obtained through a retrospective chart review of insulin pump users (ages <26 years) between December 2019 and June 2021 in an academic pediatric endocrinology practice where 68% of patients were pump users. Among 591 pump patients, 28 events occurred (3.16 events per 100 patient-years). Mean age was 13.6±3.4 years; 85.7% ranged from 12 to 19 years. Mean A1C was 10.2±2.3%, diabetes duration was 6.1±4.0 years, and 57.1% used CGM. Admission pH levels ranged between 7.0 and 7.31, with 28.6% of events classified as "moderate" and 46.4% "severe." There was no significant difference in the DKA severity between those who wore a CGM and those who did not (ie, pH, serum bicarbonate, mentation alteration, length of stay, intensive care unit admission, and hospital admission). DKA events were attributed to concurrent illness (10.7%), insulin omission (14.3%), pump site failure (57.1%), or other pump malfunctions (14.3%). DKA events in pump-treated patients were relatively uncommon; most episodes occurred in adolescents with higher A1C levels, and notably, most events could have been avoided if users followed standard troubleshooting guidelines. Thus, DKA prevention education should be reinforced at each encounter, particularly for teens with higher A1C levels. Moreover, more than 50% of those with DKA episodes wore a CGM, suggesting that pump users using CGM require frequent reinforcement of this education and that the development of such educational materials is critical.

Frequency of Ketoacidosis at Diagnosis of Pediatric Type 1 Diabetes Associated With Socioeconomic Deprivation and Urbanization: Results From the German Multicenter DPV Registry.

To investigate whether socioeconomic deprivation and urbanization are associated with the frequency of diabetic ketoacidosis (DKA) at diagnosis of pediatric type 1 diabetes. Children and adolescents aged ≤18 years, living in Germany, with newly diagnosed type 1 diabetes documented between 2016 and 2019 in the Diabetes Prospective Follow-up Registry (DPV; Diabetes-Patienten-Verlaufsdokumentation), were assigned to a quintile of regional socioeconomic deprivation (German Index of Socioeconomic Deprivation) and to a degree of urbanization (Eurostat) by using their residence postal code. With multiple logistic regression models, we investigated whether the frequency of DKA at diagnosis was associated with socioeconomic deprivation or urbanization and whether associations differed by age-group, sex, or migration status. In 10,598 children and adolescents with newly diagnosed type 1 diabetes, the frequency of DKA was lowest in the least deprived regions (Q1: 20.6% [95% CI 19.0-22.4], and increased with growing socioeconomic deprivation to 26.9% [25.0-28.8] in the most deprived regions [Q5]; P for trend <0.001). In rural areas, the frequency of DKA at diagnosis was significantly higher than in towns and suburbs (intermediate areas) or in cities (27.6% [95% CI 26.0-29.3] vs. 22.7% [21.4-24.0], P < 0.001, or vs. 24.3% [22.9-25.7], P = 0.007, respectively). The results did not significantly differ by age-group, sex, or migration background or after additional adjustment for socioeconomic deprivation or urbanization. This study provides evidence that prevention of DKA at diagnosis by means of awareness campaigns and screening for presymptomatic type 1 diabetes should particularly target socioeconomically disadvantaged regions and rural areas.

510-P: DKA Prevention on Insulin Pumps: Lessons Learned from a Large Pediatric Pump Practice

While the Type 1 Diabetes Exchange data noted that diabetic ketoacidosis (DKA) is more common in those utilizing injection regimens than insulin pumps, DKA remains a risk for pump users, as it can precipitously develop if insulin infusion is interrupted. We sought to obtain more recent DKA admission data in T1D youth using insulin pumps and the impact of CGM on DKA rates. Methods: We characterized DKA data in insulin pump users from episodes between 12/20 and 6/2021 in an academic pediatric endocrine practice in which 68% were pump users. Results: Among 591 pump patients aged &amp;lt;25 years (y) , 28 events occurred (3.16 events per 100 patient-y. Mean age was 13.6±3.4y; 85.7% were 12-19y old. More events were in males (60.7%) , 53.6% were white, 71.4% non-Hispanic. Mean HbA1c was 10.22.3%, diabetes duration 6.1±4.0y, and 57.1% used CGM; 28.6% of patients were new to pump therapy (&amp;lt;1y) .Admission pH levels ranged between 7.0-7.31, with 28.6% of events classified as “moderate” and 46.4% as “severe.” Average length of stay was 2.0±0.7 days. While there was no significant difference in pH levels, CGM wearers had higher admission bicarbonate values (11.8 vs. 9.3, p=0.04) . Clinicians assessed the cause of DKA to be related to concurrent illness (10.7%) , insulin omission (14.3%) , pump infusion site failure (57.1%) or other pump malfunctions (14.3%) . For most (60.7%) , this was the first documented DKA event. Alcohol consumption was a contributing factor in only one event. Conclusions: DKA events were relatively uncommon; most episodes occurred in adolescents in poor diabetes control. Notably, most events could have been avoided if users followed standard trouble shooting guidelines. Thus, education on DKA prevention should be reinforced at each visit, particularly for teens on pumps with higher A1c levels. Moreover, while CGM wearers had higher admission bicarbonate values, over 50% of those hospitalized for DKA wore a CGM, suggesting even pump users using CGM require frequent reinforcement of DKA prevention education. Disclosure E.Doyle: None. S.A.Weinzimer: Consultant; Dompé, Research Support; Abbott Diabetes, Speaker's Bureau; Abbott Diabetes, Dexcom, Inc. W.V.Tamborlane: Consultant; AstraZeneca, Boehringer Ingelheim International GmbH, Medtronic, Novo Nordisk, Sanofi, Takeda Pharmaceutical Company Limited.

Selecting an intervention to prevent ketoacidosis at diabetes diagnosis in children using a behavior change framework.

The rate of diabetic ketoacidosis (DKA), a preventable, life-threatening complication of diabetes, at the time of diagnosis in children remains unacceptably high worldwide. We describe our initial approach to selecting a national DKA prevention strategy, to be implemented by the Canadian Pediatric Endocrine Group DKA Prevention Working Group, informed by a framework for behavior change interventions. Existing interventions were identified from a systematic review and our own gray literature search. We then characterized interventions using the Behavior Change Wheel, a framework to inform and drive behavior change, and matched interventions to behavioral targets, audiences, and identified barriers and facilitators. Feedback from the CPEG DKA prevention working group was incorporated into the intervention plan. We identified 27 interventions. Our proposed target behaviors are: (1) prompt recognition of symptoms of diabetes in children; (2) urgent attendance to medical care with a request for an office-based test for diabetes; and (3) rapid confirmation of diagnosis and urgent consultation with pediatric diabetes experts. We initially identified four possible intervention functions including education, training, environment restructuring, and enablement. Feedback from the working group favored education intervention functions including symptom recognition messages targeting parents, caregivers, teachers, and providers and messages about how to make a rapid diagnosis and need for urgent referral targeting providers. The Behavior Change Wheel has been used successfully in selecting interventions in other clinical areas. We describe how we used this framework to provide a foundation for developing an intervention to prevent DKA at diabetes diagnosis in children.

Does the severity of diabetic ketoacidosis in children with type 1 diabetes change during the COVID-19 pandemic? A single-center experience from a pediatric intensive care unit.

During the COVID-19 pandemic, health-care services for diseases other than COVID-19 were interrupted, and patient referrals to health institutions were postponed due to their fear of being infected with COVID-19. Under this situation, we conducted this study to evaluate the clinical and laboratory findings of COVID-19 in patients with Type 1 Diabetes Mellitus (T1DM) hospitalized in our pediatric intensive care unit (PICU) with the diagnosis of diabetic ketoacidosis (DKA) during the pandemic period, and the impact of the pandemic on these findings. We retrospectively evaluated 55 children aged from 1 month to 18 years old, diagnosed with DKA, and followed up at Istanbul Sehit Prof. Dr. Ilhan Varank Sancaktepe Training and Research Hospital PICU between April 2020 and December 2021. A total of 55 patients with DKA as a complication of T1DM were admitted to the PICU during the COVID-19 pandemic. While there was no significant difference in pH and HCO3 values between those with newly diagnosed T1DM and those with previously-diagnosed T1DM, the HbA1c ratio of newly diagnosed DMs was significantly higher. Of the 55 patients, 4 were COVID-19 PCR positive, and two patients had COVID-19 antibody positivity. When COVID-19 positive patients were compared with negative patients, no significant difference was found between the hospital stay, glucose, HbA1c, lactate, pH, and HCO3 values. Higher HbA1c levels of newly diagnosed patients presenting with DKA may be associated with delayed admission to the health institutions due to COVID-19 and the length of insulin-free periods compared to pre-diagnosed patients with T1DM. In conclusion, our results, emphasize the importance of physician's and family's awareness of the symptoms of diabetes in terms of early diagnosis and prevention of DKA during public health measures due to COVID-19.

Outcome trial data on sodium glucose cotransporter-2 inhibitors: Putting clinical benefits and risks in perspective

BackgroundSodium glucose cotransporter-2 (SGLT2) inhibitors have significant heart failure and renoprotective benefits with a wide spectrum of unfamiliar and potentially serious adverse effects. Limited understanding of the risk-benefit profile of SGLT2 inhibitor treatment may result in under utilisation by prescribers and patients. MethodsData from recent seminal randomized, placebo-controlled, outcome trials for multiple SGLT2 inhibitors were incorporated. Trial populations were sub-classified into high cardiovascular risk T2DM, HFrEF, and CKD. Efficacy outcomes of heart failure hospitalisation (HFH), cardiovascular (CV) mortality, total mortality, and prevention of renal deterioration were examined. Safety outcomes included were major hypoglycaemia, diabetic ketoacidosis (DKA), urinary tract infections (UTI), mycotic genital infections (MGI), hypotension, amputations and fractures. Absolute risk reduction/increase were used to calculate number needed to treat/harm. ResultsTrial data comprised 71,545 patients, of which 53,144 were high risk T2DM, 9696 HFrEF and 8705 CKD. For HFrEF, NNT for HFH was 18, CV mortality 93, total mortality 76, prevention of renal deterioration 143 and prevention of DKA 6224. NNH for UTI was 557, MGI 356, hypotension 120, hypoglycaemia 574, amputations 707 and fractures 858. For CKD, NNT for HFH was 116, CV mortality 245, total mortality 138, and prevention of renal deterioration was 63. NNH for DKA was 1458, UTI 309, MGI 291, hypotension 165, hypoglycaemia 374, amputations 4450 and fractures 696. In the T2DM cohort, NNT for HFH was 139, CV mortality 851, total mortality 601 and prevention of renal deterioration 558. NNH DKA was 1525, UTI 239, MGI 69, hypotension 325, hypoglycaemia 472, amputations 1578 and fractures 9569. Conclusions and relevanceThe cardiovascular and renal protective benefits of SGLT2 inhibitors far outweigh the risks. This paper puts into perspective the benefits and risks of treatment with SGLT2 inhibitors for clinicians and patients.